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FRACTURES AND DISLOCATIONS 



FRACTURES 

AND 

DISLOCATIONS 

DIAGNOSIS AND TREATMENT 



BY 

MILLER E. PRESTON, A.B., M.D. 

FIRST LIEUT. M. B. C, U. S. A. ; SURGICAL EXAMINER, COLORADO STATE BOARD OF MEDICAL 
EXAMINERS ; FORMERLY POLICE SURGEON, CITY AND COUNTY OF DENVER, INSTRUCTOR 
IN ANATOMY, UNIVERSITY OF DENVER, AND VISITING GYNECOLOGIST TO 
CITY AND COUNTY HOSPITAL, DENVER, COLORADO. 



WITH A CHAPTER ON 

RONTGENOLOGY 

ByH. G. stover, M.D. 

PROFESSOR OF RONTGENOLOGY, SCHOOL OF MEDICINE, UNIVERSITY OF COLORADO; MEMBER OF 

AMERICAN RONTGEN RAY SOCIETY; VISITING RONTGENOLOGIST TO CITY AND COUNTY 

HOSPITAL, ST. JOSEPH'S HOSPITAL AND CHILDREN'S HOSPITAL, DENVER, COLORADO. 



860 ILLUSTRATIONS 



ST. LOUIS 

C. V. MOSBY COMPANY 

1915 






Copyright, 1815, by C- V. Mosby Company 



AUG 20 I9!5 C. v. MoVb7 company 



St. Louis 



CIA410338 



TO 

CHAS. B. LYMAN, M.D., F.A.C.S. 

From Whom the Author Received 

His First Instruction 

IN Fractures and Dislocations 



FOREWORD 

The object of this book has been to offer the reader a working 
knowledge of the subject in as few words as possible, avoiding for 
the most part all theories and arguments w^hich are void of practical 
value for the surgeon who has to diagnose and treat the various in- 
juries which are met with in actual practice. The author has en- 
deavored to make the reader an eye witness to the various deformi- 
ties as they appear immediately following the accident, rather than 
to offer him lengthy text in describing the lesions. There is much to 
be learned by inspection in the average case of fracture or dislo- 
cation, and the information thus gained may be put to immediate 
use with a minimum amount of manipulation of the parts and 
without being obliged to await the returns of an X-ray examination. 
The more one learns by inspection, in establishing a diagnosis in 
a given case, the less there remains to be determined by palpation, 
and if the surgeon develops the faculty of recognizing what he sees 
the patient will many times be relieved of much unnecessary manip- 
ulation and suffering to say nothing of the damage which may be 
inflicted on the already traumatized soft tissues. Photography, 
therefore, is the best means of recording the initial deformities, 
but the excitement, confusion and pain attending the average case 
of fracture are conditions anything but favorable for picture- 
taking. Moreover the varying conditions of light and the sur- 
roundings in which we find the patient, together with the neces- 
sity of having the photographic apparatus available and in good 
working order, are additional factors which work against the se- 
curing of such valuable clinical data and explain the scarcity of 
pictures of these deformities in medical literature. The illustra- 
tions of such deformities shown on the following pages have been 
taken under unfavorable circumstances, in a large proportion of 
cases, and (although the photographic appliances were the best 
obtainable including the fastest Goerz and Zeiss anastigmat lenses) 
the results, from a photographic standpoint, have been none too 
good in many instances. The pictures shown have been chosen 
from a large number of such photographs with the intention of 



Vlll FOREWORD 

familiarizing- the reader with the average clinical deformity, rather 
than for the purpose of recording rare cases or those in which the 
pathology is obscure. 

The time-honored, academic classification of fractures under one 
heading and dislocations under another has been abandoned, and 
the more practical method of considering the injuries according 
to the region in which they occur has been followed. Thus the 
reader will find all the injuries to which a given region is sub- 
ject (including fractures, dislocations, joint fractures and frac- 
ture-dislocations) without looking up the different conditions in 
widely separated sections of the book or even consulting another 
volume. 

The development of the Rontgen ray has been of inestimable 
value in the diagnosis of fractures and dislocations, and its use 
cannot be too highly commended; but, on the other hand, this 
very aid has resulted in our becoming more lax in other methods 
of diagnosis. The X-ray is a most valuable supplement to other 
physical clinical methods but it should not be expected to sup- 
plant them. The surgeon should make a practice of determining 
the nature and location of the fracture as accurately as possible 
(due care being exercised to avoid unnecessary manipulation) be- 
fore the X-ray is taken, and later to compare his conception of the 
condition with the Rontgenogram. By making this a routine meas- 
ure he will find that his diagnostic acumen will be materially in- 
creased as time goes on. 

A certain mechanical sense is most essential in the treatment of 
fractures and dislocations, and no text-book can supply this to one 
naturally deficient in this respect. However, an attempt has been 
made in the following pages to supply the necessary data for the 
development of this sense and to place before the reader, as far 
as possible, some of the author's experiences. 

The more common fractures have been accorded the greatest 
amount of attention since they are the conditions with which the 
average practitioner will have to deal most frequently. 

Occasion is here taken to thank a number of members of the 
medical profession in Denver who have been of service in various 
ways in obtaining the material for and in the preparation of this 
work. Among others the author wishes particularlj^ to express his 
gratitude to: Drs. C. B. Lyman, T. E. Carmody, Leonard Ely, 
H. R. McGraw, Benj. :D^Iatthews, V. D. McKelvey, J. M. Barney, 



FOREWORD IX 

R. K. Beere, W. G. Mudd, C. B. Ackley, H. G. Harvey, Tracey Love, 
E. AV. Lazell, W. M. Wilkinson, S. B. Childs, L. G. Crosby, J. B. 
Davis, Mr. Frank Barmettler and members of the staff and in- 
ternes of the City and County Hospital. 

Due credit for the few illustrations not original is given in the 
legends accompanying them. 

The chapter on the use of the Rontgen ray is written by Dr. H. 
G. Stover, and most of the Rontgenograms have been taken for me 
by him, or have been drawn from his collection of over thirteen 
thousand plates. 

Miller E. Preston. 
Denver, Colorado. 



CONTENTS 



PART I. 

UPPER EXTREMITY. 

Chapter ^ 

Page 

1. Fractures of the Clavicle and Injuries to the Clavicu- 
lar Articulations 3 

II. Dislocations of the Sternal End of the Clavicle 

III. Fractures of the Clavicle . . 

ly. Dislocations of the Outer End of the Clavicle 

V. Fractures of the Scapula 

VI. Dislocations of the Shoulder 

VII. Fractures of the Upper End of the Humerus 

VIII. Fractures of the Shaft of the Humerus 

IX. Fractures of the Lower End of the Humerus 

X. Dislocations of the ELBovt^ 

XI. Dislocations of the Ulna Alone (Rotary) 

XII. Dislocations of the Head of the Radius . 

XIII. Fractures of the Bones of the Forearm 

XIV. Fractures of the Upper End of the Ulna . 
XV. Fractures of the Upper End of the Radius 

XVI. Fractures of the Radial and Ulnar Shafts . 
XVIL Fractures of the Lower End of the Ulna 
XVIII. Luxations of the Lower End of the Ulna . 
XIX. Fractures of the Lower End of the Radius 
XX. Injuries to Carpus (Dislocations of Wrist, Medico-car 
PAL Luxations and Fractures and Dislocations of the 

Individual Carpal Bones) .277 

XXI. Luxations of the Carpometacarpal Articulation . . 294 
XXII. Fractures of the Metacarpals . . 297 

XXIII. Fractures of the Fingers 307 

XXIV. Dislocations of the Fingers . . .314 



5 

11 

30 

37 

44 

82 

108 

120 

154 

175 

177 

184 

185 

197 

204 

232 

237 

242 



PART II. 

HEAD AND TRUNK. 



XXV. Fractures of the Nose . 323 

XXVI. Fractures of the Malar Bone and Zygomatic Arch . . 334 
XXVII. Fractures of the Superior Maxilla .... . . 343 

XXVIII. Fractures of the Lower Jaw 348 

XXIX. Dislocations of the Jaw 376 

xi 



Xll CONTENTS 

Chapter Page 

XXX. Scalp Wounds 379 

XXXI. Fractures of the Skull . . 391 

XXXIi. Fractures of the Sternum ... 453 

XXXIII. Fractures of the Ribs 459 

XXXIV. Fracture-Dislocations of the Spine 465 

XXXV. Fractures and Dislocations of the Pelvis .... 492 

PART III. 

LO^VER EXTREMITY. 



XXXVI. 

XXXVII. 

XXXVIII. 

XXXIX. 

XL. 

XLJ. 

XLll. 

XLIIl. 

XLIV. 

XL\ . 

XLVI. 

XLVII. 

XLVIII. 

XLIX. 

L. 

LI. 

LIl. 

LIIl. 

LI\ . 

LV. 

LVI. 



Dislocations of the Hip 515 

Fractures of the Upper End of the Femur . . . .531 

Fractures of the Femoral Shaft 558 

Fractures of the Lower End of the Femur .... 574 
Fractltres and Luxations of the Semilunar Cartilages . 587 

Fractures of the Patella 594 

Dislocations of the Patella 609 

Dislocations of the Knee 613 

Injuries Just Below the Knee — Fractures of the Tibia 

AND Fibula (Upper Ends) 620 

Fractures of the Shafts of the Bones of the Leg . . 634 

Pott's Fracture 659 

Fractures of the Loaver Ends of the Tibia and Fibula . 675 

Dislocations of the Ankle 684 

Fractures and Dislocations of the Astragalus . . . 692 

Subastragalar Luxations 699 

Fractures and Dislocations of the Calcaneum . . . 703 

Medio-Tarsal Luxations 709 

Fractures and Luxations of the Cuboid, Scaphoid and 

Cuneiforms 710 

Tarso-Metatarsal Luxations 713 

Fractures of the Metatarsals . . . . . . . .714 

Fractures and Luxations of the Phalanges .... 720 



PART IV. 

SPECIAL SUBJECTS. 



L\ II. Terms and Definitions 725 

LMIl. The Use of the X-Ray. By H. G. Stover, M.D. . . . 735 

LIX. The Open Treatment of Fractures 754 

LX. Bone Transplantation 77 1 

LXI. Treatment of Compound Fractures and Dislocations . 789 



ILLUSTRATIONS. 



FIG. PAGE 

1. Muscular and ligamentous attachments of clavicle 5 

2. Superior surface of right clavicle 12 

3. Inferior surface of right clavicle 12 

4 and 5. Internal structure of right clavicle 12 

0. Relation of brachial plexus to first rib and clavicle 13 

7. Fracture of clavicle in child. Rontgenogram 13 

8. Fracture of clavicle in its inner third. Rontgenogram .... 14 

9. Greenstick fracture of clavicle. Rontgenogram 14 

10. Fracture of middle of clavicle. Rontgenogram 15 

11. Fracture of clavicle with usual deformity. Rontgenogram . . 15 

12. Comminuted fracture of outer end of clavicle. Rontgenogram . 16 

13. Comminuted fracture of clavicle. Rontgenogram 16 

14. Fracture of right clavicle (recent). Photograph 17 

15. Recent fracture of clavicle. Photograph 17 

16. Side view of same case 17 

17. Recent fracture of right clavicle. Photograph 18 

18. Side view of same case 18 

19. Fracture of clavicle 24 hours old. Photograph . . . . . .18 

20. Side view of same case 18 

21. Recent fracture of left clavicle. Photograph 19 

22. Another view of same case 19 

23. Delayed union of fractured clavicle. Photograph 19 

24. Another view of same case 19 

25. Fracture of clavicle in elderly woman. Photograph .... 20 

26. Old fracture of clavicle with deformity. Photograph .... 20 
27 and 28. Demonstrate the outlines of clavicles. Photographs . . 21 

29. Recent fracture of right clavicle 23 

30 to 33. Application of modified Sayre's dressing 24 

34. Mohr's figure-of-eight 25 

35. The application of Velpeau's bandage 25 

36. Case showing result of recumbent treatment . 26 

37 and 38. C. F. Taylor's brace 27 

39. Dislocation of outer end of clavicle and separation of acromial 

epiphysis. Rontgenogram 31 

40. Recent dislocation of outer end of clavicle. Photograph ... 32 

41. Dislocation of outer end of clavicle. Photograph ..... 33 

42. Lateral view of same case ; ... 33 

43. Downward dislocation of outer end of clavicle. Photograph . . 34 

44. Dressing for dislocation of outer end of clavicle 35 

45. Same principle carried out with adhesive plaster 35 

46. Ventral surface of right scapula 37 

47. Dorsal surface of right scapula . 37 

48. View of right scapula from axillary border 38 

49. Fracture of neck of scapula. Rontgenogram 39 

50. Palpation of scapula 41 

51. Strapping of chest for fracture of scapula 42 

52. Action of capsule in adduction of arm. Diagram 43 

53. Action of capsule in abduction of arm. Diagram 43 

54. Bones of normal shoulder 47 

55. Subcoracoid dislocation 47 

56. Intracoracoid or subclavicular dislocation 47 

xiii 



XIV ILLUSTRATIONS 

FIG. PAGE 

57. Intraclavicular dislocation with moderate deformity ..... 47 

58. Subglenoid dislocation 48 

59. Luxatio erecta 48 

60. Subacromial dislocation of shoulder 48 

61. Subspinous dislocation of shoulder 48 

62. Low subcoracoid dislocation. Kontgenogram 50 

63. Recent subcoracoid dislocation of left shoulder 52 

64. Subcoracoid dislocation of left shoulder 53 

65. Examination of same case showing depression below acromion . . 53 

66. Recent subcoracoid dislocation of right shoulder 54 

67. Another view of same case 54 

68. Another view of same case 55 

69. Recent subcoracoid dislocation of right shoulder 55 

70. Another view of same case 55 

71. Low subcoracoid dislocation of shoulder 56 

72. Low subcoracoid dislocation of shoulder 56 

73. Another view of same case 56 

74. Palpating recent subglenoid dislocation of shoulder 57 

75. Palpating recent subglenoid dislocation of shoulder 57 

76. Retentive dressing for dislocation of shoulder 58 

77. Recent typical subglenoid dislocation of left shoulder .... 59 

78. Recent subcoracoid dislocation of left shoulder 59 

79. Attitude of lea.st pain in subcoracoid dislocation 59 

80. Attitude of least discomfort in subglenoid dislocation . . . .60 

81. Another view of same case 60 

&2. Luxatio erecta 61 

83. Another view of same case 61 

84. Posterior dislocation of right shoulder 62 

85. Another view of same case. Palpation of head .62 

86. Another view of same case 63 

87. Case of avulsion of upper extremity 63 

88. Subcoracoid dislocation in fleshy woman 64 

89. Subcoracoid dislocation of shoulder in fleshy man 65 

90. Subcoracoid dislocation of right shoulder 67 

91. First step in Kocher's method 67 

92. Second step in Kocher's method 67 

93. Third step m Kocher's method 67 

94. Illustrating principles of Kocher's method 68 

95. McRurney's hook 72 

96. Dislocation of shoulder complicated by fracture of anatomical neck 

of humerus 72 

97. Rontgenogram of same case before operation .73 

98. Rontgenogram of same case after operation 73 

99. Same case after operation 74 

100 and 101. Stereoscopic Rontgenogram of fracture and dislocation of 

shoulder 74 

102. Subcoracoid dislocation with fracture of greater tuberosity . . 75 

103 and 104. Contracture following dislocation of shoulder .... 76 

105, 106 and 107. Old unreduced dislocation of shoulder .... 78 

108. Recurrent dislocation of shoulder 79 

109. Upper end of humerus- 83 

110. Structure of upper end of humerus . . 83 

111. Rontgenogram of upper end of humerus showing epiphyseal carti- 

lage 84 

112. Rontgenogram of fracture of anatomical neck of humerus ... 85 

113. Rontgenogram of fracture of surgical neck of humerus .... 86 

114. Rontgenogram of comminuted fracture of surgical neck ... 87 

115. Rontgenogram of fracture of surgical neck ! 68 

116. Rontgenogram of fracture of surgical neck ! ! 89 

117. Recent fracture of surgical neck of humerus .....!! 90 



ILLUSTRATIONS XV 

FIG. PAGE 

118. Another view of same case 90 

119. Same case seen in recumbent position 90 

120. Rontgenogram of fracture of surgical neck 91 

121. Fracture of surgical neck of humerus 91 

122. x\nother view of same case 92 

123. Rontgenogram of same case ............ 93 

124. Low fracture of surgical neck 93 

125. Same case seen in recumbent position 94 

126. Old fracture of surgical neck 94 

127. Lateral view of same case 94 

128. Rontgenogram of same case 95 

129. Measuring length of humerus 96 

130. Palpating humeral head during rotation 96 

131. Palpating humeral head through axilla 96 

132. Cigar-box boards used in making axillary pad 98 

133. Axillary pad completed 99 

134. 135 and 136. Three views of axillary pad in place ..... 99 

137. Plaster shoulder cap 101 

138. Axillary pad in position and arm bandaged 101 

139. Same after the plaster shoulder cap has been applied . . , . 101 

140. Body swathe used to secure arm to side and act as sling . . .101 

141. Middledorf triangle .............. 102 

142. Monks triangle 102 

143. Osgood-Penhallow splint 102 

144. Plaster cast applied with arm in abduction 104 

145. Plaster cast applied with arm in abduction; forearm raised , . 104 

146. Anterior surface of right humerus .......... 109 

147. Posterior surface of right humerus . 109 

148. Spiral, comminuted fracture of humerus. Rontgenogram . . .110 

149. Fracture of humeral shaft. Rontgenogram . . . . . . ,110 

150. Multiple fracture of humeral shaft. Rontgenogram . . . . . Ill 

151. Oblique fracture of humeral shaft. Rontgenogram . . . , .111 

152. Recent fracture of shaft of left humerus . . . . . . . .112 

153. Crushing injury of arm. Fracture of humeral shaft . . . .112 

154. Stromeyer cushion 114 

155. Axillary pad in place and arm bandaged . . 114 

156. Coaptation splints applied to arm 114 

157. Body swathe applied 114 

158. Rontgenogram of spiral fracture of humeral shaft . . . . .117 

159. Same after operation and reduction with internal fixation . . .117 

160. Rontgenogram of same case nine months later 118 

161. 162 and 163. Photographs of bone (same case) showing result . 118 

164, 165 and 166. Views of lower end of humerus 120 

167 and 168. Rontgenogram of fracture of lower end of humerus . . 121 

169 and 170. Rontgenogram of fracture of lower end of humerus . . 122 

171 to 174. Rontgenogram of fracture of lower end of humerus . .123 

175 to 178. Rontgenogram of fracture of lower end of humerus . . 124 

179. Epiphyseal separation of epitrochlea. Rontgenogram .... 125 

180. Lateral view of same case. Rontgenogram 125 

181. Rontgenogram of fracture of internal epicondyle 126 

182. Rontgenogram of epiphyseal separation of external condyle . . 126 

183. Rontgenogram of epiphyseal separation of internal epicondyle . 126 
1184. Recent fracture of external epicondyle with deformity . . . 129 

185. Recent fracture of lower end of humerus 130 

186. Another view of same case 130 

187. Recent fracture of lower end of humerus. (Splitting.) . . . 130 

188. Recent transverse fracture of lower end of hvimerus .... 132 

189. Another view of same case in sitting position 132 

190 and 191. Rontgenograms of same case 133 

192. Recent compound comminuted fracture of lower end of humerus . 133 



Xvi ILLUSTRATIONS 

FIG. P-^GE 

193. Another view of same case 133 

194. Recent compound comminuted fracture of lower end of humerus . 134 

195. Another view of same case 134 

196. Old gunstock deformity result of fracture above and below elbow . 135 

197. Another view of sam.e case 135 

198. Old case of diacondylar fracture of lower end of humerus . . . 136 

199. Another view of same case 136 

200. Examination of case in which carrying angle has been lost . .137 

201. Examination of same case with elbows extended . . . . . .137 

202. Examination of pronounced gunstock deformity in flexion . . . 138 

203. Same case with elbow extended 138 

204. Another view of same case 139 

205. Old fracture of lower end of humerus with musculo-spiral paralysis 140 

206. Another view of same case showing contracture 141 

207. Same case seen from ulnar side of forearm 141 

208. Case of cubitus varus in one arm and cubitus valgus in the other . 142 

209. Pronounced normal carrying angle ... - 142 

210. Dressing for treating arm with elbow in flexion 145 

211. Dupuy internal right-angle splint 146 

212. Dupuy external right-angle splint 146 

213. Internal right-angle splint applied 14G 

214. Internal right-angle splint with traction 146 

215. Plaster splints for upper extremity 147 

216 and 217. Adjustable splints for elbow 148 

218. Splitting of lower end of humerus. Rontgenogram 149 

219. Rontgenogram of same case live years after operation .... 149 
220 and 221. Range of motion in elbow of same case five years after 

operation 150 

222 and 223. Ligaments of elbow 154 

224. Recent posterior dislocation of right elbow 157 

225, 226 and 227. Additional views of same case . . . .157 and 158 

228. Recent posterior dislocation of left elbow 159 

229. Palpating head of radius and empty sigmoid in same case . . 159 

230. Posterior view of same case 160 

231. Lateral dislocation of elbow 160 

232. Another view of same case 160 

233. 234 and 235. Diagrammatic comparison of posterior dislocation of 

elbow, supracondylar and diacondylar fractures , . . . .163 

236. Swelling of elbow following simple strain 164 

237. Swelling of elbow 24 hours following dislocation 165 

238. Another view of same case 165 

239. Rontgenogram of forward dislocation of elbow with fracture of 

olecranon iq(] 

240. Rontgenogram of fracture of coronoid complicating backward dis- 

location of elbow 16(5 

241. Backward dislocation with fracture of tip of coronoid. Rontgeno- 

gram 167 

242. Backward dislocation with comminuted fracture of coronoid proc- 

ess. Rontgenogram 167 

243. Fracture of coronoid with displacement produced by backward dis- 

location of elbow. Rontgenogram 167 

244. Fracture of coronoid with slight displacement. Rontgenogram . 167 

245. Method of reducing backward dislocation of elbow . . . . . 168 

246. Another method of reducing backward dislocation of elbow . . 168 
247 and 24i8. Range of motion fourteen days following backward dislo- 
cation of elbow * 172 

249. Forward dislocation of head of radius . .179 

250 and 251. Rontgenograms of same case . . . . 170 

252. Fracture of olecranon. Rontgenogram 186 

253. Fracture of olecranon; elbow extended. Rontgenogram . . .187 



ILLUSTRATIONS XVll 

FIG. PAGE 

254. Same case: elbow slightly flexed. Rontgenogram 187 

255. Fracture of olecranon one week following accident 189 

256. Palpation of same case 189 

257. The straight splint used in the treatment of fractures of the ole- 

cranon 191 

258. Fracture of olecranon. Rontgenogram 193 

259. Same case after operation with internal fixation . . . . , . 193 

260. The use of passive motion following fracture of olecranon . . . 195 

261. Fracture of head and neck of radius. Rontgenogram .... 197 

262. Comminuted fracture of head of radius. Rontgenogram . . . 197 

263. Fracture of head and neck of radius. Rontgenogram .... 198 

264. Fracture of head of radius. Rontgenogram 199 

265. Fracture of head of radius. Rontgenogram ....... 199 

266 and 267. Gunstock deformity result of fracture of both bones of 

forearm just below elbow 201 

268. Structure of radius 204 

269. Structure of ulna 204 

270. Recent fracture of both bones of forearm 206 

271. Another view of same case 207 

272 and 273. Rontgenograms of same case 207 

274 and 275. Rontgenograms of same case after operation .... 208 

276. Recent fracture of both bones of forearm 208 

277. Recent fracture of both bones of the forearm 209 

278. Another view of same case 209 

279. Reduction of same case 210 

280. Same case seen from ventral surface of forearm .210 

281 and 282. Rontgenograms of same case after reduction .... 211 
283 and 284. Same case seen after splints have been applied . . . .212 

2185 and 286. Same case at time of removal of splints ..... 212 

287 and 288. Fracture of radial shaft 213 

289 and 290. Opposite arm of same case examined for comparison . . 213 
291 and 292. Rontgenograms of same case taken after reduction . .214 
293 and 294. Rontgenograms of same case taken after second reduction 214 
295 and 296. Rontgenograms of same case taken after operation and in- 
ternal fixation 215 

297. Fracture of both bones of forearm with unusual deformity . .215 

298 and 299. Two views of recent fracture of both bones of the forearm 216 
300. Recent fracture of both bones of the forearm near wrist . . .216 
301 and 302. Recent fracture of both bones of the forearm near wrist 

with slight deformity 217 

303. Fracture of radius and free radial styloid. Rontgenogram . . 217 

304 and 305. Rontgenogram of green-stick fracture of ulna .... 218 

306. Testing lateral spring in bones of forearm 220 

307. Recent fracture of both bones of forearm 223 

308. Same case. Deformity corrected and anterior splint applied . . 223 

309. Same case showing "cut-out" in ventral splint 223 

310. Same case. Dorsal splint applied 223 

311. Splints bandaged 223 

312. Removal of dorsal splint for inspection 224 

313 and 314. Rontgenograms of fracture of both bones of forearm with 

overriding deformity 227 

315 and 316. Rontgenograms of same case after operation and internal 

fixation 227 

317. Slight bowing of bones of forearm following imperfect reduction . 229 

318, 319 and 320. Volkmann's contracture 230 

321. Fracture of both bones of the forearm and separation of lower 

ulnar epiphysis 233 

322 and 323. Rontgenograms of same case 233 

324. Fracture and separation of lower ulnar epiphysis 234 

325. Backward dislocation of lower end of ulna 238 



Xviii ILLUSTRATIONS 

FIG ^^^^ 

326, 327, 328, 329, 330 and 331. Rontgenograms of different types of 

fracture of lower end of radius 243 

332, 333, 334. Rontgenograms of "Reversed Colles' " . . . . . • -^ 244 
335 and 336. Fracture of lower end of radius produced by "auto-kick." 

Rontgenogram 244 

337, 338 and 339. RontgenogTams of Colles' transverse Colles' fracture ^ 

with impaction 245 

340. Fracture of lower end of radius produced by auto-kick. Rontgeno- 
gram • 246 

341 and 342. Lateral and antero-posterior views of Colles' fracture 

witli slight deformity. Rontgenograms 247 

343. Rontgenogram of comminuted Colles' fracture. Rontgenogram . 247 

344 and 345. Rotgenogram of transverse Colles' fracture with impaction 248 

346 and 347. RontgenogTams of oblique Colles' fracture 248 

348 and 349. Rontgenograms of separation of lower radial epiphysis 

complicated by fracture 249 

350 and 351. Separation and fracture of lower radial epiphysis . . 250 

352 and 353. Separation and fracture of lower radial epiphysis . . 250 

354. Recent typical Colles' fracture 252 

355. Recent Colles' fracture 252 

356. Recent Colles' fracture showing radial displacement of hand . . 253 

357 and 358. Tavo views of recent Colles' fracture 253 

359. Recent Colles' fracture showing displacement of articular surface 254 

360 and 361. Two views of recent Colles' fracture ...... 254 

362 and 363. Two views of recent Colles' fracture 255 

364 and 365. Two views of recent Colles' fracture 255 

366 and 367. Two views of recent oblique Colles' fracture .... 256 

368 and 369. Two views of separation of lower radial epiphysis . . 258 

370. Another view of same case 259 

371. Recent epiphyseal separation of lower end of radius .... 259 

372. Same case immediately following reduction ....... 259 

373. Radial view of recent Colles' fracture • 261 

374. Ulnar view of recent Colles' fracture 261 

375. Same case. Ventral view 261 

376. Same case. Comparison of levels of two styloids 261 

377. Same case. Comparison of levels of two styloids 261 

378 and 379. Photographic comparison of Colles' fracture and backward 

dislocation of wrist 262 

380 and 381. Radial and ulnar views of recent Colles' fracture . . . 263 
382 and 383. Same case showing two methods of reducing Colles' frac- 
ture 264 

384. Diagrams illustrating principles involved in reducing Colles' frac- 
ture ....... 264 

3185. Flat ventral splint 265 

386. Flat dorsal splint 265 

387. Flat dorsal splint with "ulnar cut-out" 265 

388. The Walker splint 266 

389. Short splints and adhesive; for Colles' fracture 267 

390. Proper position for carrying wrist in sling 267 

391. Improper position for carrying wrist in sling 267 

392. Rontgenogram showing radial epiphysis displaced to radial side . 270 

393. Same case after operation and internal fixation 270 

394. Colles' fracture 24 hours old. Swellino- pronounced .... 272 
395 and 396. Old Colles' fracture with deformity 273 

397. Old Colles' fracture with deformity . . *. 274 

398. Loss of function following Colles' fracture 274 

399. Rontgenogram of same case showing osteitis of carpus .... 274 
400 and 401. Contracture following Colles' fracture ......'. 275 

402 and 403. Ligaments of wrist 277 

404. Rontgenogram of normal bones of carpus and metacarpus . . . 278 



ILLUSTRATIONS XIX 

FIG. PAGE 

405. Old Colles' and anomalous triangulare 270 

400. Old Colles' and anomalous triangulare 279 

407. Rcintgenogram of anomalous centrale 279 

408. Rontgenogram of anomalous space corresponding to centrale . . 279 

409. Old united fracture of scaphoid 280 

410. Rontgenogram of fracture of semilunar 280 

411. Rontgenogram of fractured scaphoid 280 

412. Rontgenogram of fractured semilunar 281 

413 and 414. Rontgenograms of luxated semikmar 281 

415 and 416. Old Colles' fracture and abnormal condition of scaphoid. 

Rontgenogram , . 282 

417. Rontgenogram of "Divided Scaphoid" 283 

418. Centrale present and fused with os magnum. Rontgenogram . . 284 

419. Rontgenogram of Colles' fracture and fractured trapezium . .284 

420. Severe compound fracture dislocation of wrist . . . . . .287 

421. Old injury of carpus 288 

422. Rontgenogram of Bennett's fracture ......... 297 

423. RontgenogTam of gunshot fracture of metacarpal 298 

424. Recent Bennett's fracture 299 

425. 426 and 427. Recent Bennett's fracture 300 

428. Recent fracture of index metacarpal 301 

429. Fracture of metacarpals 301 

430. Fracture of metacarpal 302 

431 and 432. Recent fracture of metacarpal 302 

433. Old fracture of fourth metacarpal 303 

434, 435, 436 and 437. Roller bandage dressing for fracture of meta- 

carpals 304 

438. Compound fracture of base of terminal phalanx 308 

439. Severe compound fracture of phalanges . 308 

440. Plaster splint for thumb 309 

441. Plaster splint for finger 309 

442. Board splint for finger 310 

443 and 444. Goldthwaite tin splint for fracture of thumb . . . .311 

445. Tin splint applied to finger . . . . . . . . . . . .311 

446. Claw nail resulting from injury to finger . . . . , . .312 

447. Dislocation of thumb .............. 315 

448 and 449. Compound lateral dislocation of thumb 315 

450. Old unreduced lateral dislocation of thumb ....... 450 

451 and 452. Recent dislocation of finger 316 

453. Ventral dislocation of second knuckle . . . . . , . . ,316 

454. Dorsal dislocation of finger 316 

455. Backward luxation of second joint of middle finger 316 

456 and 457. Sagittal section through the nasal cavity 323 

4518. Old fracture of nasal bones with lateral displacement .... 326 

459. Old fracture of nasal bones with lateral displacement .... 326 

460. Separation and lateral displacement of lateral and septal cartilages 326 

461. Fracture of nasal bones and partial separation of cartilages . 326 
462 and 463. Destruction of nasal bridge from syphilis 327 

464. Falling in of nasal cartilages in old case of syphilis ... . . 328 

465. Saddle nose in hereditary syphilis 328 

466. Raising the depressed nasal bones . 329 

467. Packing nasal cavities . 329 

468. Asche nasal splints 329 

469. Author's moulded dental composition splint 330 

470. The Cobb nasal splint 330 

471. Relations of the nasal, lachrymal, superior maxilla and malar bones 33.) 

472. Zygomatic arch seen from below 335 

473. Recent fracture of left malar bone 337 

474. Fracture of malar bone 24 hours after injury 337 

475. Fracture of malar and zygoma 338 



XX ILLUSTRATIONS 



FIG, 



PAGE 



476. Old fracture of malar 341 

477 and 478. Old fracture of malar with great deformity . . . .341 

479. Superior maxilla 343 

480. Fracture of superior maxilla 345 

481 and 482. Two views of inferior maxilla 348 

483. Recent fracture of inferior maxilla at symphysis 351 

484. Rontgenogram of same case 351 

485. Fracture of lower jaw just anterior to right canine 352 

486. Fracture of lower jaw 352 

487. Fracture of lower jaw between canine and lateral incisor . . . 353 

488. Fracture of lower jaw anterior to first molar 354 

489. Old fracture of jaw with deformity 355 

490. Fracture of lower jaw behind last molar 355 

491. Rontgenogram of same case 356 

492 and 493. Fourtailed bandage made of adhesive . . .... 358 

494. Interdental splint of vulcanite 359 

495. Metal dental splint with arms for counter-pressure 361 

496. Vulcanite splint with arms for counter-pressure 361 

497. Matas splint for fracture of lower jaw 362 

498 and 499. Heath metal splint 363 

500. Edmund's forceps for clamping metal splint to teeth .... 364 

501. Cast aluminum splint cemented to teeth 364 

502. Oliver's method of wiring the lower to the upper law . . . 366 
503 and 504, Manner of placing loops in wiring jaws together . , 369 
505 and 506, Wiring jaws together. Four points of fixation , . . 369 

507. Jaws wired together in fracture of lower jaw 370 

508 and 509. Angle's bands and bars 371 

510 and 511. Angle's bands with knobs 371 

512. Scalp wound prepared for suture 387 

513. Same case. Sutures in place 387 

514. Same case. Bandaged 387 

515. Interior surface of right half of skull 397 

516. Interior surface of right half of base of skull 398 

517 and 518. Craniometric points of importance 400 

519. Most common sites of meningeal hemorrhage 400 

520. Cortical centers 400 

521. Old depressed fracture of vault 413 

522. Old depressed fracture of frontal reaion 414 

523. Old depressed fracture of skull in left parietal region . . . .414 

524. Old depressed fracture of vault 415 

525. Fracture of base of skull 415 

526. Old depressed fracture of frontal region . 416 

527. Severe fracture encircling skull 416 

528. Severe compound, comminuted fracture of vault 417 

529. Severe gvmshot fracture of skull 417 

530. Rontgenogram of bullet within skull 418 

531. Swelling and ecchymosis about eyes suggestive of fracture of skull 419 

532. Calvarium of patient who previously had depressed compound frac- 

ture of vault 419 

533 and 534. Diagrams indicating steps in performing osteoplastic oper- 
ation on skull . . • 447 

535. DeVilbiss bone cutting forceps 448 

536. Small trephine ! ! ! 448 

537. Relations of sternum 453 

538. RontgenogTam of fracture of sternum [ [ 455 

539 and 540. Reduction of fracture of sternum " 457 

541. Rontgenogram of fractures of third, fourth, fifth and sixth ribs 460 

542. Caving in of chest 4gl 

543. Fracture and displacement of costal cartilage . . . 461 

544. Adhesive plaster strapping for fracture of ribs . . . . ! 463 



ILLUSTRATIONS XXI 

FIG. PAGE 

545. Rontgenograiii of fracture of cervical spine 466 

546. Eontgenogram of fracture-dislocation of cervical spine .... 467 

547. Rontgenogram of dislocation between first and second cervical verte- 

br^ 468 

548. Rontgenogram of fracture of the lower dorsal and upper lumbar 

vertebrae 469 

549. 550 and 551. Two views and section of old fractured spine . . . 470 

552. Rontgenogram of fracture of spine 471 

553. Rontgenogram of fracture of body of fifth lumbar vertebra . .472 

554 and 555. Fracture of cervical spine 474 

556 and 557. Fracture of lower dorsal spine 475 

558. Old fracture of lower dorsal spine 477 

559. Charco's spine 477 

560. Methods of wiring spine 488 

561. Incisions used in performing a laminectomy and in making osteo- 

plastic flap ' 489 

562. The pelvis 492 

563. Lateral view of pelvis 493 

564. Rontgenogram of fracture of pelvis through acetabulum . . . 494 
565 and 56Q. Fracture of ilium and tearing away of abdominal muscles 499 

567. Rontgenogi'am of lateral dislocation of coccyx . . . . . .501 

568. Double plaster spica used in treatment of fracture of pelvis . . 50S 

569. The ilio-femoral or Y-ligament of Bigelow .516 

570. Iliac dislocation of hip 517 

571. Sciatic dislocation of hip , 517 

572. Ilio-pectineal dislocation of hip 518 

573. Pubic dislocation of hip 518 

574. Obturator or thyroid dislocation of hip 518 

575. Perineal dislocation of hip 518 

576. Everted dorsal dislocation of hip . . . . . . . . . .519 

577. Attitude in dorsal dislocation of hip 521 

578. Attitude in anterior dislocation of hip 521 

579 and 580. Old unreduced dorsal dislocation of hip 522 

581. Reduction of dorsal dislocation of hip 525 

582. Stimson's method of reducing luxations of hip 526 

583. Author's modification of Bigelow's method , . . . . , . 526 

584. Allis' method of securing pelvis to floor 527 

585 and 586, Internal structure of upper end of femur 531 

587, Nelaton's line and Bryant's triangle. Diagram ...... 534 

5i88, Rontgenogram of impacted fracture of femoral neck .... 535 

589. Rontgenogram of old ununited fracture of femoral neck . . . 589 

590. Rontgenogram of impacted fracture of neck of femur .... 589 

591. Rontgenogram of fracture of femoral neck 535 

592. Rontgenogram of fracture of rim of acetabulum . . . . . 536 

593. Rontgenogram of fracture of great trochanter 536 

594. Rontgenogram of middle of femoral neck 536 

595. Rontgenogram of base of femoral neck with splitting off of lesser 

trochanter 536 

596. Impacted fracture of neck of femur 538 

597. Impacted fracture of neck of femur . 538 

598. Fracture of right femur through great trochanter 538 

599. Fracture of femur just below great trochanter 538 

600. Drawing Nelaton's line on patient 539 

601 and 602. Measuring length of lower extremity 540 

603 and 604. Diagrams showing effect of tipping of pelvis . . . .541 
605. Relaxation of fascia lata result of raising of trochanter . . .541 
606 and 607, Application of Buck's extension 543 

608. Weight used with Buck's extension 543 

609. Pulley used witli Buck's extension 543 

010. Long'T-splint 544 



Xxii ILLUSTRATIONS 

FIG. P^«E 

611. T-splint applied and extension in use 544 

612. Diagram showing principles of Ruth-Maxwell method .... 546 

613. The use of sand bags in fracture of hip 546 

614. Plaster cast applied with thigh abducted 547 

615. Plaster cast applied with hip and knee semiflexed ..... 548 

616. Author's screw plates for internal fixation of fracture of the hip 550 

617. Usual sites of fracture through femoral neck . . . . . .551 

618. Tendency to displacement when screw is used in fixation of hip . 551 

619. Author's screw plate in position 551 

620. The Thomas hip splint 553 

621. The ambulatory pneumatic splint 554 

622. Diagrams illustrating the development of coxa vara after Whit- 

man 556 

623. Anterior surface of femur 559 

624. Posterior surface of femur 559 

625. Rontgenogram of transverse fracture of femoral shaft . . . 560 

626. Recent fracture of right femoral shaft 561 

627. Old fracture of right femoral shaft 561 

628. Recent fracture of left femoral shaft 562 

629. Recent fracture of left femoral shaft 562 

630. Correction of deformity by lateral traction. Diagram .... 564 

631. Adjustable inclined plane 564 

632 and 633. Treatment of fracture of femoral shaft in children by 

suspension 565 

634. The Bradford frame 565 

635. The Nichols frame 569 

636. Rontgenogram of double spiral fracture of shaft of femur . . . 570 

637. Rontgenogram of same case after operation 570 

638. Rontgenogram of same case two years after operation . . . .571 

639. Rontgenogram of same case six years after operation . . . .571 

640. Lateral surface of lower end of femur 575 

641. Internal structure of lower end of femur 575 

642. Rontgenogram of knee showing locations of epiphyseal cartilages 576 

643. Fracture of low^er end of femur with angular deformity. Rontgeno- 

gram 577 

644. Supracondylar fracture with pronounced overriding. Rontgeno- 

gram . 577 

645. Rontgenogram of old displaced fracture with refracture through 

callus 577 

646. Rontgenogram of fracture of femur with lateral deformity . . 577 

647. Fracture of lower third of shaft of femur ....... 578 

648. Compound comminuted fracture of lower end of femur . . . . 578 

649. Cabot posterior wire hip splint , 580 

650. Same, bent to form double inclined plane 580 

651. Dupuy's splint used as double inclined plane 581 

652. Dupuy's splint 581 

653. Adjustable double inclined plane fracture box 582 

654. Hogden's splint 582 

655. Adjustable ambulatory pneumatic splint 585 

656 and 657. Subluxation of knee with lateral dislocation of patella and 

displacement of semilunar cartilage 589 

658. Old fracture of patella with separation of fragments . . . . 596 

659. Fracture of both patellae 596 

660. Dressing for fracture of patella 598 

661. Ham splint . . . 599 

662. Silver wire mattress suture of patella ] i 600 

663. Internal structure of patella 600 

664. Rontgenogram of recent fracture of patella ....... 601 

665. Same case after operation ' qqi 

666. \Yired fracture of patella three years after operation . . . . 603 



ILLUSTRATIONS XXlll 

FIG. PAGE 

667. \Yired fracture of patella two years after operation .... 603 

668. Passive motion in after-treatment of fracture of patella .... 606 

669. Diagram of normal relations of patella . . . . . . , .610 

670. Diagram of lateral dislocation of patella . ,610 

671. Diagram of rotary displacement of patella and lateral dislocation 

"on edge"' ..*........,,..... 610 

672 and 673. Ligaments of knee . , 614 

674. Lateral view of upper epiphysis of tibia. Kontgenogram . . . 621 

675 and 676. Anomalous ossification of upper end of tibia .... 622 

677 and 678. Rontgenogram of vertical fracture of upper end of tibia . 623 

679. Rontgenogram of fracture of upper end of tibia 623 

680. RontgenogTam of splitting of upper end of tibia 623 

681. Fracture of upper end of tibia ........... 625 

682. Fracture of upper end of right tibia ~ ......... 626 

683. Compound fracture of both bones of the leg 636 

684. Fracture of both bones of the leg . . 636 

685. Compound fracture of both bones of the leg ....... 636 

686 and 687. Fracture of both bones of the leg 637 

688. Fracture of both bones of the leg . . 638 

689. Same case four days later showing blood blebs ...... 638 

690. Green-stick fracture of tibia in child 639 

691. Compound fracture of both bones of leg ........ 639 

692 and 693. Fracture of tibia near ankle ......... 640 

694 and 695. Severe compound comminuted fracture of both bones of leg 641 

696 and 697. Severe compound fracture of both bones of the leg . . 642 

698. Folding fracture-box laid open 643 

699. Same box closed .643 

700. Padding used with fracture-box and method of holding box to- 

gether 643 

701 and 702. Use of fracture-box in treating fractures of the leg . . 644 

703 and 704. Short Desault splint 645 

705. The Cabot posterior wire splint 646 

706. The N. R. Smith splint . 646 

707. Elevated fracture-box 647 

708. Cradle used to keep bed clothes off leg ....... . 647 

709 and 710. Methods of securing traction on fractures near the ankle 647 

711. Use of old shoe and adhesive in obtaining extension ..... 647 

712. Padding to relieve heel from pressure 647 

713. Plaster of Paris splints for fracture of leg 648 

714. Plaster stirrup for fractures of the leg ........ 648 

715 and 716. Two views of comminuted fractures of tibia and fibula 

near ankle. Rontgenograms 651 

717. Rontgenogram of same case after operation . 652 

718. Same case. Anterior plaster splint removed to show field of opera- 

tion 652 

719. Ambulatory pneumatic splint as applied to fractures of the leg . 655 

720. Old fracture of tibia and fibula with discharging sinus . . . 656 

721. Persistent swelling following fracture of leg 656 

722. 723, 724 and 725. Diagrams illustrating the manner in which the 

leg is thrown "oft' center" when union occurs with deformity . . 657 
726 and 727. Normal relations of the calcaneum, astragalus and bones 

of the leg ..... 660 

728. Rontgenogram of normal ankle showing epiphyses 661 

729. Rontgenogram of Pott's fracture 662 

730. Rontgenogram of variant of Pott's fracture 662 

731. 732 and 733. Rontgenogram of Pott's fracture 662 

734 to 737. Rontgenogram of Pott's fracture 663 

738. Rontgenogram of old Pott's fracture 663 

739. RontgenogTam of Pott's fracture. Lateral view 663 

740. Recent Pott's fracture of left ankle . ". 664 



Xxiv ILLUSTRATIONS 

PAGE 

■pTfJ 

7-41 and 742. Two views of a recent Pott's fracture OJJJ) 

743. Another view of same case J^>J|J,> 

744. Recent Pott's fracture seen from behind «)<>^ 

745. Same case after deformity has been corrected Mu 

746. The making and application of the Dupuytren splint .... ()W) 

747 and 748. Stimson's plaster splints • • f'*^*] 

749 and 750. Rontgenograms of splitting of lower end of tibia . . . (Wo 
751, 752 and 753. Rontgenograms of fractures of internal malleolus 

at different levels • ^>7<' 

754. Epiphyseal separation of lower end of tibia complicated by frac- 
ture «^() 

755 and 756. Supramalleolar fracture 677 

757 and 758. Supramalleolar fracture 677 

759 and 760. Supramalleolar fracture with pronounced deformity . . 679 

761 and 762. Splitting of lower end of tibia 680 

763. Old fracture of both bones of the leg with baclovard displacement 681 

764 and 765. Ligaments of ankle 685 

766 and 767. Inward fracture-luxation of ankle 688 

768. Anterior dislocation of ankle 688 

769 and 770. Antero-posterior and lateral views of fracture-luxation 

of astragalus. Rontgenogram 692 

771. Rontgenogram of lateral dislocation of astragalus 693 

772. Deformed astragalus removed to restore function 697 

773 and 774. Compound subastragalar luxation 700 

775. Rontgenogram of fracture of calcaneum ........ 704 

776. Anomalous trigonum 704 

777 and 778. Rontgenograms of fractures of calcaneum 704 

779 and 780. Crushing injuries of tarsus 711 

781 and 782. Rontgenograms of fractures of fifth metatarsals . . .715 

783. Oblique fracture of shaft of fifth metatarsal 716 

784. Rontgenogram of fracture of base of fifth metatarsal . . . .716 

785. Rontgenogram of compound crushing injury of metacarpus . . .716 

786. Method of detecting fracture in the metatarsal bones . . . .717 

787. Crushing injury of foot 717 

788. Example of simple transverse fracture. Rontgenogram . . . 726 

789. Example of multiple fracture. Rontgenogram 726 

790 and 791. Surface form and section of fracture united in deformity 727 
792 and 793. Rontgenograms of carcinoma of bone with spontaneous 

fracture 728 

794. Carcinoma of lower end of femur with extensive destruction of 

bone. Rontgenogram . 729 

795. Syphilitic dactylitis with spontaneous fracture. Rontgenogram . 730 

796. Spontaneous fracture following osteo-sarcoma 730 

797. Osteo-carcinoma with spontaneous fracture. Rontgenogram . .731 

798. Case of fetal rickets with spontaneous fracture. Rontgenograms . 732 
799 to 802. Rontgenograms of lower extremities of same case . . . 733 

803. The Rose portable coil 738 

804. The Rose portable coil. Larger instrument 739 

805. Special type of Crook's tube 740 

806. Metallic numbers for -marking X-ray plates ....... 740 

807 and 808. Diagram illustrating use of X-ray , 742 

809, 810 and 811. Diagram illustrating use of X-ray . . . . . 743 

812. Radio-chronometer . 746 

813. The Bauer qualimeter 746 

814. Linear fracture of upper end of tibia 747 

815 and 816. Antero-posterior and lateral views of fracture of radius. 

Rontgenograms 74g 

817 to 820. Four Rontgenograms of same case taken from different po- 
sitions 749 

821 and 822. Stereoscopic Rontgenogram 75X 



ILLUSTRATIONS XXV 

FIG. PAGE 

823. Methods of using wire in internal fixation of fractures .... 758 
824 and 825. An example of the use of a single loop of wire . . .759 

820. Instruments serviceable in passing wire about bone 760 

827. The Lane bone drill 760 

828 and 829. Bone forceps 761 

830. Gerster's turn-buckles 762 

831. Appliance for holding plate in position 763 

832. Compound fracture of both bones of the leg 704 

833. Same case after fixation with Freeman's clamp 764 

834. Set of Lane's bone plates 765 

385. Comparison of wood screw and Sherman's "tap-screw" . . . 766 

830. Sherman's tap-screws and screw driver 766 

837. Examples of broken plates . . 767 

838 and 839. Antero-posterior and lateral views of fracture of both 

bones of leg. Rontgenograms 767 

840 and 841. Antero-posterior and lateral views of same case two 

years later. ,Plate in place. Rontgenograms 767 

842. Infected tibia from which Lane plate has been removed. Rontgen- 

ogram 769 

843. Old imunited fracture of tibial shaft. Diagram 778 

844. Same, after ends are squared and medullary cavity reamed out. 

Diagram ^ 778 

845. Same with medullary dowel graft in place. Diagram 778 

846. Making saw cuts in obtaining medullary graft. Diagram . . .779 

847. Removing medullary graft with chisel. Diagram 779 

848. Removing medullary graft with rotary saw. Diagram . . . .779 

849. Inlay graft in place. Diagram 782 

850. Method of securing same with kangaroo tendon. Diagram . . . 782 

851. Motor saw equipment including twin saws 783 

852. Doweling machine 783 

853. First step in Albee's technique in recent fractures. Diagram . . 784 

854. Same with "short piece" removed. Diagram 784 

855. Same with "long piece" held in place by bone pegs. Diagram . . 784 

856. Upper end of humerus replaced by upper end of fibula. Diagram . 786 

857. Loss of tibial shaft. Diagram 787 

858. Same after upper end of fibular shaft has been implanted in upper 

tibial fragment. Diagram 787 

859. Same after operation has been completed 787 

860. Gangrene of leg following thrombosis 792 



PART I. 
UPPER EXTREMITY. 



rRACTlEES AND DISLOCATIONS 



CHAPTER I. 

FRACTURES OF THE CLAVICLE AND INJURIES TO 
THE CLAVICULAR ARTICULATIONS. 

The clavicle may be fractured by direct or indirect violence, or 
either end of the bone may be dislocated. The early ossification 
of the clavicle accounts for the frequency with which it is fractured 
in children, and the fact that the sterno-clavicular ligaments 
extend outward onto the diaphysis, explains the rarity of separation 
of the single clavicular epiphysis situated at the inner end of the 
bone. Dislocation of either end of the clavicle is rare as compared 
with fracture. Males are more subject to injury of this bone and 
its articulations because of their occupations, and heavier muscula- 
ture. The coraco-clavicular ligaments are an important element 
in determining the site of fracture when due to indirect violence, 
and in limiting the displacement in both fractures and dislocations. 
The stability of either end of the clavicle depends on ligaments, 
rather than the conformation of the articular surfaces. The 
acromial end is dislocated nearly four times as often as is the 
sternal end, while all the dislocations of the clavicle make up about 
four percent of the luxations of the entire body. Dislocations of 
both ends of the bone, and simultaneous dislocations of both 
clavicles, are conditions which have been recorded, though they 
are extremely rare. 

Injuries to the clavicle and its articulations will be taken up in 
the following order: 

Dislocation of the sternal end. 
Forward. 
Backward. 
Upward. 

Fracture of the clavicle. 

3 



4 FRACTURES AND DISLOCATIONS 

Dislocation of the acromial end. 

Upward. 

Downward. 

Sub-coracoid. 
Fracture of this bone is so common and dislocation so rare that 
examination of the ends of the clavicle is often neglected, espe- 
cially in the presence of fracture. The fact should never be lost 
sight of that two or more lesions may be present at the same time. 
A systematic examination of the entire region should be made in 
addition to determining the condition of the bone in question. 
The surgeon should remember that the examination is not neces- 
sarily concluded with the finding of a given lesion ; further damage 
may have been done to adjoining bones or joints. Particularly, 
care should be exercised in examining children because of the mild 
and indefinite character of the symptoms accompanying the frac- 
ture of the clavicle in the early years of life. 



CHAPTER II. 

DISLOCATIONS OF THE STERNAL END OF THE 
CLAVICLE. 

Surgical Anatomy. — The articular end of the clavicle is much 
larger than the articular facet on the sternum, and the integrity of 
the joint is almost entirely dependent on the ligaments that sur- 
round the joint and bind the two bones together. The capsule is 
attached to the margins of the two articular surfaces and com- 
pletely encloses the joint cavity. It is reinforced in front and 
behind by the anterior and posterior sterno-clavicular ligaments. 
To the inner side and above, it is overlaid by the interclavicular 



■^ 






/CC, : 


D 


Ph 


' ^ 


s 


: Mi 


«l^ 


■^k 


i 



Fig. 1. — Muscular and lig-amentous attachments of the clavicle. T., trapezius; S.M., 
sterno-mastoid ; D., deltoid; P.M., pectoralis major; B., biceps; R., rhomboid ligament; 
C.C., coraco-clavicular ligament; A.G., acromio-clavicular ligament; C.A., coraco-acromial 
ligament. The interclavicular ligament may be seen attached to the upper aspfect of the 
inner end of the bone. 

ligament which is attached to both clavicles. Externally the 
rhomboid ligament, extending from the under surface of the clavicle 
to the cartilage of the first rib, greatly strengthens the articulation. 
This ligament is in relation posteriorly with the subclavian vein. 
The ends of the bones entering into this articulation are ver}^ poorly 
adapted to each other and when dislocation takes place recurrence 
of deformity is prompt, unless prevented by retentive dressings. 
The rhomboid ligament is seldom completely torn and will tend to 
limit the displacement. 



6 FRACTURES AND DISLOCATIONS 

Displacement of the sternal end is usually the result of indirect 
violence. If the long axis of the clavicle is continued inward it 
will pass in front of the sternum, and accordingly the most common 
type of luxation of the sternal end is forward. The displacement 
may be partial or complete and accordingly the condition is spoken 
of as either a luxation or a subluxation. Forced backward dis- 
placement of the shoulder may produce a luxation of the inner 
end of the clavicle by leverage against the first rib. 

Forivard dislocation is by far the most common luxation seen at 
this joint, and is usually the result of the shoulder having been 
driven forcibly backward beyond the normal limitation of motion. 
If the shoulder be carried backward the inner end of the clavicle 
comes in contact with the first rib, and if forced still further back- 
ward this contact with the first rib acts as a fulcrum by means of 
which the inner end of the bone is torn away from the sternum and 
displaced forward. This mechanism seems to be the usual cause 
of displacement, though there are some instances in which the 
condition has taken place gradually and has apparently been the 
result of a general relaxation of the ligaments about the joint. 

Backiuard luxations are not as common as the type just described, 
though they are next in order of frequency. They are usually the 
result of violence which forces the shoulder forward and inward, 
though they are sometimes caused by a direct force which drives 
the inner end of the clavicle backward. The trachea, oesophagus 
and the large vessels of the neck lie behind the inner end of the 
clavicle, and when a posterior displacement occurs any or all of 
these structures may be pressed upon. 

Upward luxation of the sternal end of the clavicle is extremely 
rare and is usually the result of violence which depresses the 
shoulder. The ligaments are more or less torn according to the 
severity of the causative trauma. Luxations of the inner end of 
the clavicle are rare, as compared with fractures of the clavicle. 

Symptoms. — Pain is more or less pronounced at the site of the 
lesion and is increased with motion of the shoulder. Loss of 
function varies with the completeness of the dislocation and the 
amount of pain suffered by the patient. There is more or less 
swelling about the inner end of the bone. The deformity varies 
with the direction of the luxation. 

In forward luxations the inner end of the bone is more prominent 
than normal and is often found displaced downward onto the 



DISLOCATIONS OF STERNAL END OF CLAVICLE 7 

anterior surface of the sternum, as well as forward. The lowered 
position of the inner end of the bone changes the axis of the clavicle, 
which deformity can often be recognized by inspection alone. 

In backward luxations it will be noted that the normal promi- 
nence of the inner end of the clavicle is absent, and the axis of the 
bone is changed. Palpation of the shaft of the clavicle will dis- 
close the altered position. Passive congestion of the face on the 
side of the luxation may be present, and in severe cases cyanosis 
may be pronounced. Dysphagia and dyspnoea are not uncommon. 
The acuteness of these symptoms usually subsides even though the 
displacement be allowed to go uncorrected. There is no reported 
case of permanent injury to tlie structures thus pressed upon and 
accordingly these symptoms are not alarming. The shoulder is 
displaced downward and forward and is a little nearer the thorax 
than normal. This displacement is often slight and if the shoulder 
is not compared with the opposite side the deformity may go 
unrecognized. 

In upward luxations there is a variable amount of disturbance 
in function and pain at the seat of injury. Inspection and palpa- 
tion will show the change in the axis of the bone and the upward 
displacement of the inner end. The inner end of the bone is 
abnormally mobile. 

Diagnosis. — The clavicle is subcutaneous throughout and the 
sternal notch may be palpated without difficulty. Accordingly 
displacements of the inner end of the bone are easily determined. 
Differentiation of fractures of the clavicle from luxations of the 
inner end presents no particular difficulty unless the swelling is 
pronounced. In fractures of this bone crepitus is almost invariably 
distinct, and the absence of this symptom in luxations is significant. 
The distance between the tip of the acromion and the middle of the 
suprasternal notch is lessened in both fractures and luxations. 
Dislocations of the inner end of the clavicle are not infrequently 
overlooked because of associated lesions which are more evident. 
The X-ray is of value as a routine measure but is seldom necessary 
to establish the diagnosis. 

Treatment.— Reduction is, as a rule, easily accomplished but it 
is usually a difficult matter to retain the articular surfaces in their 
proper relations. Certain positions are known to be favorable in 
the prevention of the recurrence of deformity but the surgeon 
should determine for himself in each and ever}^ case just what 



8 FRACTURES AND DISLOCATIONS 

position is most favorable in holding the articular surfaces in 
apposition. 

In forward luxations the condition is easily recognized and there 
is little difficulty in reducing the displacement. Outward and 
upward traction on the shoulder with direct pressure on the end 
of the bone will usually be all that is necessary to effect reduction. 
The displacing action resulting from contact between the clavicle 
and first rib is avoided by preventing extreme backward displace- 
ment of the shoulder during the after-treatment. Any form of 
dressing which will properly immobilize the shoulder without 
carrying it too far backward will accomplish' the desired result. 
When the ligamentous tearing has been extensive it may be neces- 
sary to employ some form of dressing which will support the 
weight of the upper extremity and overcome the action of the 
muscles which pull the shoulder downward, forward and inward. 
In accomplishing this purpose care should be exercised not to pull 
the shoulder too far backward. A figure-of-eight of both shoulders 
with the turns passing in front of the chest, and another figure-of- 
eight with the turns across the back will fix the shoulder sufficiently 
for all practical purposes. A plaster of Paris spica will immobilize 
the shoulder very perfectly but is seldom necessary. It is often 
advisable to employ direct pressure over the sternal end of the 
clavicle by means of pads and strips of adhesive plaster. When 
pressure is used in this way it should be remembered that the end 
of the bone is subcutaneous and that sloughing of the skin may 
follow if the pressure is too severe or too long continued. It is 
probably better to exert the pressure over the inner two inches 
of the shaft rather than directly over the end of the bone. The 
necessity for direct pressure will depend on the tendency to recur- 
rence of deformity after the shoulder has been fixed. There is 
probably no dressing which will perfectly fill all requirements in 
all instances. Each ease must be considered by itself and the par- 
ticular dressing employed is of secondary moment, provided the 
shoulder is immobilized with the luxation in reduction and in a 
position showing the least tendency to the recurrence of deformity. 
It will be found practically impossible to entirely correct the 
anterior displacement, but absolute reduction is not essential to 
complete restoration of function, and the slight deformity remain- 
ing is of little moment. 

Young women may be desirous, for cosmetic reasons, of securing 



DISLOCATIONS OF STERNAL END OP CLAVICLE 9 

as perfect reduction as possible, and in such instances the shoulder 
should be fixed and the displacement treated in the recumbent 
position for a period varying from ten days to two weeks. 

In backward dislocations of the inner end of the clavicle reduction 
is accomplished by traction upward, outward and backward, and 
is, as a rule, attended by little difficulty. If additional manipula- 
tion is required the clavicle may be grasped in its middle third, 
where it is free from heavy muscular attachment, and direct trac- 
tion made to replace the inner end of the bone as the shoulder is 
being pulled outward and backward. Reduction is much more 
easily maintained than in the forward variety, though the shoulder 
should be immobilized and the case kept under observation as in 
forward dislocations. The shoulder may be immobilized by the 
double figure-of-eight as already described, or the Velpeau or Sayre 
dressing may be employed. (See Figs. 30 to 35.) Direct 
pressure over the inner end of the bone is seldom required in this 
form of luxation. 

In upivard luxation of the ster no-clavicular joint, reduction is 
accomplished by outward traction on the shoulder accompanied by 
direct downward pressure on the inner end of the clavicle. Main- 
taining the end of the bone in "proper position is attended with 
difficulty here, as in other types of luxation at this joint. The 
shoulder should be immobilized and the arm supported to prevent 
downward displacement. If there is much displacement of the 
clavicle it may be well to place a pad in the axilla, and bind the 
arm to the side to maintain the proper distance of the shoulder 
from the thorax. The principles involved in the treatment of this 
dislocation are similar to those already described in the two pre- 
ceding types of luxation. 

Operative Treatment. — Operative intervention is, as a rule, 
indicated only in old cases with loss of function, and in cases of 
recurrent dislocation which have not responded to non-operative 
measures. Proper reduction can almost invariably be had in recent 
cases by proper fixation, but should recurrence of deformity take 
place in spite of appropriate dressings, it may be advisable to 
expose the end of the bone and secure it in position with suture. 

An incision parallel to the clavicle is made exposing the parts; 
the end of the clavicle is then dissected out from the fibrous tissue 
which surrounds it in its displaced position in old cases. It is 
then returned to its proper relation with tlie stennim and fixed in 



10 FRACTURES AND DISLOCATIONS 

position. It may be possible in some cases to repair the ligaments 
sufficiently to retain the end of the bone in place. In other 
instances it may be necessary to drill holes in the end of the clavicle 
and the upper end of the sternum and prevent recurrence by some 
form of suture material, either absorbable or otherwise. The rela- 
tion of the great vessels of the neck should be kept in mind when 
operating in this region. In cases of recurrent or habitual disloca- 
tion a repair of the ligaments wdll frequently be all that is required. 
The same results have been obtained by the repeated injection of 
small quantities of alcohol in the region of the anterior sterno- 
clavicular ligament, thus producing inflammatory reaction and 
secondary fibrosis. Resection of the articular end of the clavicle, 
with the subsequent formation of a false joint, is a method which 
has been followed by excellent results in habitual luxations. 

Operative treatment is rarely indicated in backward or upward 
luxations, but should the necessity arise for open treatment in 
either type the principles will be the same as already given. 

After-Treatment. — In simple cases the retentive dressings may 
be dispensed with at the end of a month, and pressure over the 
sternal end is seldom of use after ten days to two weeks. During 
the progress of the case the dressings should be examined frequently 
to correct alteration in position, and when pressure is employed 
the parts should be carefully watched so that irritation of the 
skin may be immediately detected if it appears. Activities sub- 
jecting the articulation to much strain should be avoided for 
another month to six weeks following removal of all dressings. 
"WTien these simple details are followed the patient will almost 
invariably make a perfect functional recovery, though there is 
usually some prominence remaining at the site of the dislocation. 
The after-treatment is the same in all forms of luxation of the 
sterno-clavicular joint. 

Prognosis. — "With proper reduction and immobilization restora- 
tion of function should be practically complete. If the end of 
the bone is allowed to remain in displacement there will be more 
or less loss of function. If strain is placed on the joint too soon 
following the initial luxation the condition may become recurrent. 



CHAPTER in. 

FRACTURES OF THE CLAVICLE. 

Surgical Anatomy. — The clavicle is the most frequently broken 
single bone in the entire body, and this fact renders a study of its 
anatomy particularly advisable. This fracture is especially com- 
mon in children. The clavicle is the only bone connecting the upper 
extremity with the trunk, and its position is quite superficial. 
These two facts expose the bone to fracture, both from direct and 
indirect violence. The most common fracture is the result of 
indirect violence and the break is usually situated at or near the 
junction of the outer and middle thirds where the two curves 
of the shaft meet, and the bone changes in form from *' prismatic" 
to ''flat." 

The shaft of the clavicle is well ossified before birth, and the bone 
has but one epiphysis which is situated at the sternal end. This 
single epiphysis begins to ossify at about the eighteenth year and 
joins the shaft during the twenty-fifth year. The ligaments of the 
sterno-clavicular articulation extend beyond the epiphysis and are 
attached to the shaft of the bone so that epiphyseal separations are 
almost never seen. 

The clavicle is situated in a muscular plane which should be 
understood to appreciate the displacements which take place when 
fracture occurs. On the inner end of the bone is attached the 
clavicular origin of the sterno-mastoid above, while opposite it on 
the anterior and lower aspect of the bone is attached the clavicular 
origin of the pectoralis major. In the presence of fracture in the 
usual site, it might seem that these muscles would counteract each 
other, but if the direction of the fibres of these two muscles is 
observed it will be noted that those of the pectoralis approach the 
bone at an acute angle, while the clavicular head of the sterno- 
mastoid is placed at nearly right angles with the shaft. This gives 
the sterno-mastoid the mechanical advantage, and accordingly the 
inner fragment is displaced upward. The subclavius is attached 
to the inferior surface of the shaft, in its middle third, and when 

11 



12 FRACTURES AND DISLOCATIONS 

the bone is broken and depressed against the first rib and the 
structures passing into the axilla, it acts, to some extent, as a 
cushion. To the anterior border of the outer third is attached the 
deltoid, and on the posterior border of the same corresponding 
portion of bone is found the clavicular insertion of the trapezius. 
These two muscles about balance each other and are seldom respon- 
sible for displacement of fragments. The ligaments of the 
clavicle play an important part in preventing and limiting dis- 
placement of the fragments. The rhomboid ligament is a heavy 







P 


rll 


^^^^'i ^^^^^1 


^^^^D 



Fig. 2. Fig. 3. Fig. 4. Fig. 5. 

Figs. 2 and 3 show the siiperior surfaces of the right clavicle. Dotted lines indicate 
the margins of muscular and ligamentous attachments. 

Figs. 4 and 5 show the internal structure of the same bone. Note the preponderance 
of compact tissue in the shaft and region corresponding to the oblique line. 

structure which passes from the first costal cartilage to the under 
surface of the inner end of the clavicle. The sterno-mastoid usually 
displaces the inner fragment upward until this ligament becomes 
taut, when further deformity is checked. When the fracture lies 
internal to the coraco-clavicular (coronoid and trapezoid) ligament 
the inner fragment is free to move upward, while the outer frag- 
ment falls downward, inward and forward Avith the shoulder. 
When the fracture passes through this ligament both fragments 
remain attached to the coracoid and displacement is slight or 
absent. Fractures of the clavicle between the coraco-clavicular and 
acromio-clavicular ligaments are usually not accompanied by much 
deformity. 



FRACTURES OF THE CLAVICLE 



13 



It is not often necessary to operate on the clavicle, but when the 
occasion does arise the surgeon should appreciate the internal 
structure of the bone. Figs. 4 and 5 show a horizontal section 
of the bone. The clavicle is composed largely of compact tissue, 
the cancellous bone being confined to the extremities. The compact 




Fig. 6. — Diagram shoAving the relations of the brachial plexus to the first rib and 
clavicle. Section of clavicle removed. 

tissue is particularly heavy in the region of the oblique line where 
the coraco-clavicular ligaments are attached. 

The clavicle is subcutaneous throughout and easily palpated. It 
should be noted that the acromion stands directly external to the 




\ 



Fig. 7. — Fracture of the clavicle with overriding deformity in a child. 



outer end of the bone, as well as behind it. The rounding of the 
outer aspect of the shoulder is caused by the head of the humerus 
beneath the deltoid, and not by either clavicle or acromion. 

Any portion of the clavicle may be broken, but by far the most 
common site of fracture is in the outer end of the middle third and 



14 



FRxVCTURES AND DISLOCATIONS 



is decidedly oblique. Fracture in this region is usually the result 
of indirect violence and is almost always produced by a fall on the 
shoulder. Trauma sustained in this way more often produces a 




Fig. 8. — Fracture of the clavicle in its inner third. No deformity, 




Fig. 9. — Green-stick fracture of the clavicle. 



dislocation of the shoulder in adults, while in children fracture is 
more common because the clavicle is relatively weaker. Incom- 
plete fracture is common in children. Fractures in either the 



FRACTURES OF THE CLAVICLE 



15 



inner or outer third are comparatively rare and usually the result 
of direct violence. Muscular action is sometimes, though rarely, 
responsible for fracture of the clavicle. 

It should be remembered that fracture internal to the coraco- 
clavicular ligament completely destroys all bony and ligamentous 




Fig. 10. — ^Fracture of the middle third of the clavicle with the usual deformity — up- 
ward displacement of the inner fragment. 





Fig. 11, — Fracture of the clavicle with the usual deformity. 



connection between the scapula and sternum, but when the break 
occurs through, or external to, this ligament, a heavy bond is main- 
tained between the inner fragment and the shoulder blade. 
Simultaneous fracture of both clavicles is occasionally seen as a 
result of transverse crushes of the shoulders. 

Symptoms. — The patient complains of pain immediately follow- 
ing the accident, and there is almost complete loss of function 



16 



FRACTURES AND DISLOCATIONS 




Fig. 12. 



uacture of the outer end of the clavicle (rare). 




Fig. 



13. — Comminuted fracture of the clavicle with overridinj 



as a result of pain and of the disturbed mechanism of the shoulder. 
Swelling usually develops within a few hours and obliterates the 
supra- and infra-clavicular fossae. The surgeon can hardly fail 
to recognize the obliteration of these fossae if the opposite shoulder 
is inspected and compared. If the inner fragment is free of the 
coraco-clavicular ligament the deformity will be so pronounced that 
the nature of the injury should be recognized by inspection alone. 
The shoulder is displaced inward, forward and downward, the 
injured member is supported with the opposite hand and the head 



FRACTURES OF THE CLAVICLE 



17 



is inclined to the injured side to relax the pull of the sterno-mastoid. 
The patient is unable to draw the shoulder forward, as shown in 
normal cases in Figs. 27 and 28. The inner fragment is usually 




Fig. 14. — Fracture of the right clavicle about twenty minutes after the accident. 
The injiiry was sustained by a fall on the shoulder. Note the swelling in the region of 
the fracture and the slight falling of the shoulder. The manner in which the patient 
grasps and supports the injured member is characteristic. If need be the diagnosis 
might be made by inspection alone. Palpation reveals abnormal mobility and crepitus 
at the site of fracture. 




Fig. 15. 




Fig. 1( 



Figs. 15 and 16. — Front and side views of fracture of the clavicle with moderate 
deformity. Note the prominence produced by the outer end of the inner fragment. 
Photographs taken about thirty minutes following the accident. 

displaced upward and can, as a rule, be palpated and moved 
without difficulty. The nearer the fracture is situated to the inner 
third of the bone the more pronounced will be the angle of upward 



18 



FRACTURES AND DISLOCATIONS 



displacement. The distance between the supra-sternal notch and 
the acromion process is decreased on the injured side; in other 
words the shoulder is shortened. When the fracture lies through 




Figs. 17 and 18. — Fracture of the right clavicle at about its middle. Note the 
prominence of the outer end of the inner fragment. Photographs taken about twenty 
minutes following the accident. 




Fi2. 19. 



Fig. 20. 

iurv ^'NotP^^tbrilH^T"J/^.^*^''-^ •''^ L*^*^'^^^i'^^ ^^°^* twenty-four hours following in- 
sula and i^fv.rL f^i"*^ i^^ '""^^'r^t^ shoulder and the swelling which obliterates the 
lirj,eri^t£'if7o'A'^Z t'7..cZr!s'irt^l\:^r ^'^ ^^^-^^^ displacement of the 

or external to the coraco-clavicular ligament the deformity will 
usually be too slight to recognize by inspection, and the patient will 



FRACTURES OF THE CLAVICLE 



19 



not show the usual anxiety in supporting the injured member. 
Pain, local tenderness and less pronounced loss of function will, 
however, be present. If the surgeon fixes the shoulder with one 
hand, the fingers of the opposite hand will detect abnormal mobility 




Figs. 21 and 22. — Fracture of the left clavicle with pronounced upward displace- 
ment of the inner fragment which is not bound down by the coraco-clavicular ligament. 
The following points are significant in making a diagnosis from inspection alone: 
Contour of shoulder normal, axis of arm normal, shoulder as a whole slightly lowered 
and patient grasps forearm. Deformity of clavicle plainly visible as well as palpable. 
Photographs taken a few minutes following the accident. 




Fig. 23 



Figs. 23 and 24. — Delayed union of clavicle due to poor approximation of frag- 
ments. The inner fragment is above and anterior to the external fragment. This de- 
formity is chiefly the result of the action of the clavicular attachment of the_ sterno- 
mastoid. Fracture nearer the median line than usual. Injury the result of direct 
violence. Patient first seen by author six weeks after the accident. 

by alternate forward and backward pressure on the clavicle, in 
the region of the fracture. The middle third of the clavicle is free 
from heavy muscular attachments and can be grasped without diffi- 
culty in testing the integrity of the bone. When the normal 



20 



FRACTURES AND DISLOCATIONS 




Fig. 25. — Fracture of the left clavicle in an elderly woman some days following 
the accident. Note the ecchymosis in the region of the fracture and the obliteration 
by swelling of the supra- and infra-clavicnlar fossae. Falling of shoulder not apparent 
because elbow is supported by the arm of the chair. 




Fig. 26. — Fracture of right clavicle with pronounced deformity following improper 
treatment. This case (according to the historv given bv the patient) was treated by 
means of a plaster cast of the shoulder and the deformity recognized only when the 
dressing was removed some weeks later. Function of shoulder much impaired and 
symptoms of brachial ple.xus irritation present. This condition is a striking example 
of what may follow treatment which is not based on proper principles 



FRACTURES OF THE CLAVICLE 



21 



shoulder is thrown forward this middle third stands out promi- 
nently as shown in Figs. 27 and 28. 

Ecchvmosis usually develops within the first day or two and is 
almost pathognomonic of fracture. 

In children the fracture is often incomplete and the symptoms 
are much less pronounced. Local tenderness and pain are present 
but the child may not show any perceptible disturbance in the use 
of the arm and hand. Move commonly, however, there is a disin- 





Fig. 27. 

Figs. 27 and 28. — These two pictures were taken to demonstrate the manner in 
which the outlines of the clavicles may be brought out by throwing the shoulders for- 
ward. This movement not only brings out the outline of the bone but shows whether 
or not the clavicle is properly performing its function. If the clavicle is fractured the 
action of the shoulder will be qiiite different when the patient is requested to throw 
the shoulder forward. In adipose and well-muscled persons it is more difficult to see 
the outline of the clavicle, yet the signs and symptoms of fracture are almost always 
sufficiently pronounced to form a diagnosis if the examiner is observant and systematic. 



clination to use the hand of the injured side and the patient will 
cry out when the arm, forearm or shoulder is manipulated. Local 
swelling is usually present. When the fracture is complete the 
symptoms will be more pronounced though deformity is almost 
always slight in children. 

Fracture of the clavicle is rarely compound and injury to the 
structures passing beneath the clavicle are rare, considering the 
frequency with which the clavicle is fractured. If the brachial 
plexus or axillary artery is injured symptoms of paralysis or nerve 
irritation or disturbance in the circulation of the upper extremity 
will develop. 

Crepitus is a sj-mptom which can almost always be elicited in 



22 FRACTURES AND DISLOCATIONS 

fractures of the clavicle, except in the incomplete form occurring 
in children. 

Diagnosis. — There is, as a rule, little difficulty in recognizing 
fracture of the clavicle if the region of the shoulder is carefully 
examined. The diagnosis is based on the symptoms just given. 
Incomplete fractures in children, and fractures of the outer end 
of the bone are most likely to be overlooked. In establishing a 
diagnosis of fracture of the clavicle it is not sufficient to note the 
presence of a break in a given region^ but the entire shoulder should 
be examined to exclude associated lesions. The clavicle should be 
palpated from end to end; occasionally the fracture is multiple. 
The spine of the scapula and the acromion should be palpated and 
the condition and position of the upper end of the humerus should 
be determined. The circulation of the forearm should be exam- 
ined and the reflexes noted. 

Treatment. — Reduction of the deformity in fractures of the 
clavicle is usually a simple matter, being accomplished by pulling 
the shoulder outward, upward and backward. The deformity 
recurs, however, as soon as the parts are released. Correction of 
the displacement, therefore, is useless prior to the application of 
retentive dressings. 

Innumerable dressings have been devised for maintaining the 
fragments in reduction, but only those which have proven most 
satisfactory wall be considered. 

The modified Sayre adhesive plaster dressing will be found most 
satisfactory in the largest number of cases and is applied with 
three strips of adhesive plaster, each about four inches wide and 
long enough to encircle the trunk one and a half times. Zinc-oxide 
plaster should be used as it is less irritating. Before the adhesive 
is applied the axilla should be cleansed, and the arm and chest 
sponged with alcohol and thoroughly dried. ^A folded towel should 
be placed in the axilla or a few layers of gauze secured in position 
to prevent the arm from coming in contact with the chest. If the 
upper extremity is immobilized and skin is allowed to come in 
contact with skin, cutaneous irritation is almost sure to follow and 
may be severe. A light folded towel or folded gauze should also 
be placed about the middle of the arm before the first strip of 
adhesive is applied. 

The first stnp of adhesive encircles the arm (the loop being 
secured with a safety pin) half way between the shoulder and 



FRACTURES OF THE CLAVICLE 



23 



elbow; the strip is then continued under tension, across the back, 
under the opposite arm and on to the chest anteriorly. This strip 
of adhesive, when in place, should pull the arm well backward. 
The portion of the dressing encircling the arm should be equi- 
distant from the shoulder and elbow ; neither above nor below this 
point. The second strip begins behind the shoulder, extends down 
the back of the arm, under the elbow, along the dorsal surface of 
the forearm and hand, and over the opposite shoulder. As this 
strip passes under the elbow the adhesive should be split and a 
generous padding of cotton placed in position to prevent irrita- 




Fig. 29. — Fracture of the right clavicle with the usual symptoms. The following 
figures show the application of a modified Sayre's dressing to this case. 

tion at the point of the elbow. As the end of the strip is being 
attached to the opposite shoulder the hand should be raised on the 
chest and the elbow pulled forward. This second strip pulls the 
elbow forward (thus displacing the shoulder backward with the 
middle of the arm fixed by the first strip) and raises the entire arm. 
"When these two straps are in position the shoulder is pulled 
upward, backward and outward, thus meeting the requirements for 
reduction of the displaced fragments. A third strip of adhesive 
plaster is then passed horizontally around the chest and arm to 
fix the arm to the side. Instead of this strip a body-swathe may 
be used to steady the member. This dressing, when properly 
applied, immobilizes the shoulder most satisfactorily. The author 
has found, however, that the patient usually complains of the 
confinement of the hand which often shows considerable irritation 



24 



FRACTURES AND DISLOCATIONS 





Jeig. 30. 



Fig. 31. 




K II 





Fis. 33. 



Author's modification of a Sayre"s dressing applied to the fractured clavicle shown 
in Fig. 29. In this dressing the hand is not included, which is a gi-eat comfort to the 
patient and does not render the dressing less effective. Sayre's dressing will meet the 
indications better in the greatest number of cases. When employed in the treatment of 
children, special care should be 'taken in watching for signs of irritation to the delicate 
skin. (See Figs. 37 and 38. — The Taylor brace, which is of great advantage in the 
treatment of children.) 



Fig. 30. — First strap of adhesive encircles the 
arm backward. 



rm and then the body, pulling the 



Fig. 31. — Second sti'ap of adhesive passing down the posterior aspect of the arm, 
under the elbow and over the opposite shoulder. 

Fig. 32. — Third strap of adhesive which passes down the outer side of the arm, 
under the elbow and under the hand to the opposite shoulder. 

Fig. .33. — Another view of the dressing showing the attachment of the straps poa 
teriorly. 



FRACTURES OF THE CLAVICLE 



25 



where it comes in contact with the adhesive. To obviate this the 
author has been in the habit of dividing the second strip into two 
narrow strips applied as shown in Figs. 32 and 33. The first 
strip passes down the posterior aspect of the arm, under the elbow, 
and then diagonally across the forearm so that it passes above the 
hand and over the opposite shoulder. The second strip passes 
down the outer side of the arm, under the elbow on its outer aspect, 
and then diagonally across the forearm in the opposite direction 
so that it passes below the hand and over the opposite shoulder. 
The hand is thus left exposed and free from irritation, and the 
patient may move it at will, thus relieving the discomfort of the 
cramped position without in any way disturbing the fixation. (See 
Figs. 29 to 33.) In some instances, especially when the fracture 
is in the inner half of the bone, additional direct pressure may be 





Fig. 34. — Mohr's figure-of-eight. 



Fig. 35. — Shows the turns used in Vel- 
peau's bandage. 



necessary to prevent upward displacement of the inner fragment. 
This is accomplished by means of pads of gauze or cotton held in 
position by strips of adhesive. 

AVhen adhesive plaster is not available Mohr's figure-of-eight, 
Velpeau's bandage or a posterior figure-of-eight with the turns 
passing behind the shoulders will serve the purpose as an emergency 
dressing. These dressings, however, are all too insecure to be 
relied upon in permanent fixation of the clavicle. 

The recumbent position will almost invariably maintain the frag- 
ments in good position when all forms of ambulatory treatment 
prove inefficient. The patient should be placed on a firm narrow 
bed, the arm secured to the side by means of a swathe, and a small 
firm pillow placed between the scapula? and fixed in position on 



26 



FRACTURES AND DISLOCATIONS 



the back by means of strips of adhesive. Multiple fracture of the 
clavicle or simultaneous fracture of both clavicles can be success- 
fully treated by this method. (See Fig. 36.) 

The test of any dressing is the position occupied by the fragments 
and the absence of undue constriction of the arm and forearm. No 
matter what method is employed either the presence of deformity 
or strangulation of the upper extremity is a condition which calls 
for correction and indicates the inefficiency of the dressing. 

In adults, especially large persons, considerable strength is 
necessary in the dressing to maintain the proper position of the 




Fig. 36. — In difficult cases recumbent treatment will give good results when other 
methods would fail. This photograph was taken about tive years after fracture of both 
clavicles (one clavicle in two places) and fracture of the first and second ribs on both 
sides. Recumbent treatment was employed. At the time this photograph was taken it 
was impossible to determine by palpation the former positions of the fractures in the 
clavicles. 

upper extremity, and accordingly the points of greatest pressure 
(the middle of the arm and the point of the elbow in Say re's 
dressing) should be particularly well padded. 

Taylor's brace (see Fig. 37) is especially well adapted to frac- 
tures of the clavicle in children, and allows freedom of motion of 
both arms. Sayre's dressing, however, will answer the purpose 
very well, though the delicate skin of a child must be closely watched 
for irritation when adhesive plaster is employed. 

Operative Treatment.— Nearly all cases of fractured clavicle can 
be successfully treated either by Sayre's dressing or the recumbent 
method and hence operative intervention is rarely indicated in 



FRACTURES OF THE CLAVICLE 27 

recent cases. AYhen, however, operation is demanded a single loop 
of suture material will usually accomplish all that is required to 
hold the fragments in position; the Lane plate is almost never 
needed. The incision is best made a little below and parallel to the 
bone, rather than directly on it. If the incision is a little below 
the clavicle a short flap may be made, and the danger of infecting 
the wound from the cut skin edges will be lessened. 

Most surgeons prefer absorbable suture material (such as kanga- 
roo tendon) to wire, in securing the ends of the fragments. In 
operating on the inner end of the bone the surgeon should have in 






Fig. 37. Fig. 6c. 

Figs. 37 and 38. — The C. F. Taylor brace which is particularly satisfactory in the 
treatment of fractures of the clavicle in children. 

mind the relations of the important structures passing between the 
clavicle and the first rib. The subclavian vein lies directly behind, 
and in contact with, the clavicle and subclavius muscle, and just 
external to and behind the rhomboid ligament. A little external 
to the vein and separated from it by the scalenius anticus is the 
subclavian artery, which is also in relation with the clavicle and 
subclavius muscle. If the surgeon does not exercise great care 
either of these vessels may be injured, thus giving rise to serious 
and troublesome hemorrhage. External to the artery is the brachial 
plexus descending from the neck into the axilla. Fortunately 
however fracture of the clavicle in the region of these structures is 
rare. 

Operation is sometimes demanded in old cases because of injury 



28 FRACTURES AND DISLOCATIONS 

to the brachial plexus with resultant paralyses. These injuries are 
usually due to pressure alone (without laceration of the nerves) and 
if the condition is not too old removal of pressure, by dividing the 
bone and raising the depressed fragment, will be all that is required. 
Following operation it will, as a rule, be wise to fix the parts with 
a Sayre's dressing to relieve the internal fixation of as much 
strain as possible. 

After-Treatment. — Sayre's dressing is the most secure known, 
yet it requires watching from day to day to correct slipping and to 
take up the slack as it develops. The fact that reduction is perfect 
and immobilization is secure after the dressing is in place should 
not lead the surgeon to assume that the same conditions will prevail 
a week later.* 

Most text-books advise the removal of the dressing at the end of 
a few days to inspect the skin for evidences of irritation and to see 
that reduction is maintained. This will seldom be needed if the 
dressing has been properly applied in the first place. Additional 
strips of adhesive following the course of the ''second strip," as 
described in the application of Sayre's dressing, may be used as 
needed to raise the elbow and correct the downward slipping. The 
case should be carefully watched for signs of cutaneous irritation, 
strangulation of the circulation of the arm and for the partial recur- 
rence of deformity. 

In the uncomplicated case in a child, union may be expected at 
the end of two and a half or three weeks, though the callus at this 
time is in no condition to withstand any considerable strain. In 
adults a month or a little more is necessary for the fragments to 
unite. The dressings maj^ be removed at the end of three to five 
weeks, according to the age of the patient, and the arm carried in a 
sling for another week or ten days. During the after-treatment the 
dressing should be changed every ten days and the parts carefully 
inspected and cleansed. In removing the dressing the patient is 
best placed in the recumbent position so that the clavicle will not 
be subjected to strain during the change from the old dressing to 
the new. Care should be exercised not to pull the shoulder forward 
as the old dressing is being removed and the new one applied. 
With the upper extremity released it is well to fully extend the 
elbow and gently abduct the shoulder without disturbing the 
clavicle. This will aid in keeping these joints free, and will be 
followed by more rapid resumption of function when the dressings 



FRACTURES OF THE CLAVICLE 29 

are permanently removed. If the dressings are replaced in the 
sitting position the surgeon should have an assistant to confine 
his entire attention to holding the shoulder upward, backward and 
outward while the dressings are being changed. Massage and 
passive motion should be instituted as soon as the dressings are 
permanentl.v removed, but care should be exercised not to submit 
the clavicle to strain before the callus is well formed. These 
measures are of the greatest value in keeping up the tone of the 
muscles and in maintaining the integrity of the articular surfaces 
following operations on the nerves, pending the regeneration of 
these structures. 

Prognosis. — In the usual fracture of the clavicle complete resto- 
ration of function and strength should follow proper treatment. 
If the fragments have been allowed to unite in deformity there 
will be some loss of function, varying with the degree of deformity, 
and if the brachial plexus is impinged upon there may be a more 
or less complete paralysis of the upper extremity. If the disturb- 
ance in function is due simply to mechanical causes surprising 
improvement may take place as the years go by. The complication 
most often rendering the prognosis bad is injury to the brachial 
plexus. When this structure is damaged the outlook will depend 
on the nature and extent of the injury, and the length of time the 
paralysis has been established. AVith paralysis existing a year or 
two there is little chance of improving the condition by operation, 
but even under these circumstances there is everything to gain and 
nothing to lose, and it is advisable, therefore, to expose the plexus 
and do what can be done by relieving pressure and suturing divided 
nerve ends. In recent cases the prognosis is not bad if operated 
early, although the process of regeneration may extend over months 
or even a year. 

In the uncomplicated case of fracture of the clavicle the prog- 
nosis is good whether in child or adult, provided proper treatment 
is carried out. 



CHAPTER IV. 

DISLOCATIONS OF THE OUTER END OF THE CLAVICLE. 

Surgical Anatomy. — The acromio-clavicular articulation is of 
the arthrodial type and is composed of two small, nearly flat, oval 
facets, one on the acromion and the other on the outer end of the 
clavicle. The plane of this articulation is not at right angles with 
the long axis of the clavicle but is so placed that the clavicular 
facet looks downward, outward and backward. The result then 
(when the acromion is forced inward toward the base of the neck) 
is that the clavicle will tend to slip upward onto the top of the 
acromion. Violence of this type, however, is more likely to pro- 
duce fracture of the clavicle than dislocation of either end. An 
inter-articular fibro-cartilage is sometimes present between the two 
articular facets. The joint depends entirely on the ligaments sur- 
rounding it and those passing between the coracoid and the clavicle. 
The coraco-clavicular ligaments play an important part in reinforc- 
ing this joint and are usually torn when the displacement is 
pronounced. 

Nearly all the dislocations of the acromio-clavicular joint are of 
the upward type. About a dozen cases of downward luxation have 
been reported. Another form of dislocation is one in which the 
clavicle is displaced downward and forward beneath the coracoid 
process, but the few cases reported are questionable and the type is 
doubtful. 

The upward luxation is described as complete or incomplete, 
according to whether or not the articular facets clear each other. 
The acromio-clavicular ligaments are more or less completely torn, 
and the coraco-clavicular ligaments may be partially or completely 
ruptured, depending on the extent of the displacement and the 
degree of violence. 

Direct violence is usually responsible for luxations of the acromio- 
clavicular joint, though muscular action is known to have produced 
the condition. A downward blow on the acromion may displace 
this process downward while the clavicle is prevented, to some 

30 



DISLOCATIONS OF OUTER END OF CLAVICLE 31 




Fig. 39. — Dislocation of the outer end of the clavicle and separation of acromial 
epiphysis. The lower ai'row points to the displaced epiphysis. 



32 FRACTURES AND DISLOCATIONS 

extent, from accompanying it by the action of the trapezius. The 
same type of violence which produces fracture of the clavicle may 
in rare instances he responsible for luxations of the outer end. 

Symptoms. — Dislocations of the clavicle vary with the direction 
of the displacement and the extent of ligamentary rupture. There 
is always more or less pain in the region of the acromio-clavicular 
articulation which is increased by both active and passive motion 
of the shoulder. Disabilitv varies greatly in different cases. Com- 




Fig. 40. — Dislocation of the outer end of the clavicle a few minutes following the 
accident. Note the prominence indicated by the arrow. 

plete loss of function may be -present in some cases while in others 
the patient may be able to use the shoulder, though the action of 
the part is more or less restricted by pain. It is probable that this 
variation in disability depends largely on the extent of laceration 
in the coraco-clavicular ligaments. The nature of the deformity 
varies with the type of luxation. 

In the common upward variety a distinct prominence is noted at 
the outer end of the clavicle. In the incomplete form the promi- 
nence of the displaced outer end is not great, being as a rule less 
than the thickness of the bone. In the complete form the outer end 
of the bone stands out prominently and may be moved about on 
palpation. By pressing on the outer end of the clavicle and raising 



DISLOCATIONS OF OUTER END OF CLAVICLE 



33 



the shoulder, the prominence may be made to disappear as the luxa- 
tion is reduced. Recurrence of deformity is prompt with release 
of the shoulder, A rotary displacement of the scapula is noted 
in some instances; the tip of the body being more prominent than 
normal, while the spine and acromion are depressed. If the 
clavicle is grasped in its middle third, where it is free from heavy 
muscular attachments, and manipulated, pain will be produced at 
the outer end. 




Figs. 41 and 42. — Dislocation of the acromial end of the clavicle shortly following 
accident. Note the forward and downward displacement of the shoulder and the ab- 
normal prominence of the outer end of the clavicle which slightly overlaps the acromion. 
Further displacement is prevented by the coraco-clavicular ligaments which remain intact. 

In the downivard type of luxation the outer end of the bone lies 
below the acromion and is displaced backward. The middle third 
of the shaft is less prominent than normal, the trunk is inclined to 
the injured side and the shoulder is lowered. The downward dis- 
placement of the outer end causes the sternal extremity to become 
unduly prominent. The entire inner border of the acromion is 
palpable and the articular facet may be felt. It will usually be 
possible to feel the clavicle at the point where it passes under the 
acromion. 

In the suhcoracoid form the clavicle is said to be lodged under 
the coracoid process. The outer end of the bone lies in the axilla 
and there is great ecchymosis in the region of the coracoid. 

Diagnosis. — In the usual type of acromio-clavicular luxation the 



34 FRACTURES AND DISLOCATIONS 

diagnosis may be tentatively made by inspection alone. The nature 
and position of the prominence is characteristic. Manipulation of 
the clavicle or shoulder causes motion at the acromio-clavicular 
joint. The region of the prominence should be carefully palpated 
to exclude fracture of the outer end of the clavicle, and fracture of 
the acromion. Either of these conditions is productive of crepitus. 
The ligaments sometimes avulse a small portion of either clavicle 
or acromion in lieu of rupture of the ligament itself, and when this 




Fig. 43. — Down^vard dislocation of the outer end of the clavicle. The outer end 
of the clavicle is caught under the acromion and the patient assumes this attitude as 
the one of least discomfort. 

occurs the surgeon may be able to elicit crepitus and mistake the 
condition for fracture. Careful palpation, however, will determine 
the false motion in the joint itself and not to the outer or inner 
side of it. The displaced axis of the clavicle and the relatively 
raised acromion should suggest the condition in the rare downw^ard 
type. 

Treatment. — In the common type of luxation reduction is, as a 
rule, easily effected by upw^ard, outward and backward traction on 
the shoulder. Recurrence of deformity, however, is the rule and 
retentive dressing should be at hand to maintain the outer end 
of the clavicle in position as soon as reduction is accomplished. 
Stimson's adhesive plaster dressing is quite satisfactory in prevent- 



DISLOCATIONS OF OUTER END OF CLAVICLE 



35 



ing redisplacement. The axilla is first cleansed, sponged with 
alcohol, and dried and a folded towel is placed between the arm and 
the chest to prevent skin coming in contact with skin during the 
subsequent immobilization. The arm is then placed at the side 
and the elbow semiflexed. A strip of adhesive four feet long and 
three or four inches wide is then placed under the elbow. One end 
is carried up the anterior aspect of the arm and over the shoulder 
at the site of luxation. The posterior end of the plaster is carried 
up the posterior aspect of the arm in a similar manner and carried 
forward over the shoulder. As the ends of this dressing are being 




Fig. 45. 



Fig. 44. — Dressing to maintain reduction in luxation of the outer end of clavicle. 
Fig. 45. — Same principle carried out with adhesive plaster instead of bandage. Note 
the pad over outer end of clavicle. 

brought into position the shoulder should be raised upward, back- 
ward and outward, and pressure should be made on the outer end 
of the clavicle. When the plaster is properly placed it pulls 
upward on the semiflexed elbow and exerts downward pressure on 
the outer third of the clavicle. The arm is then secured to the side 
by means of a body swathe and the forearm carried in a sling. 

In the downward type of luxation reduction is accomplished by 
outward traction on the shoulder and direct manipulation of the 
clavicle by grasping it in its middle third. Recurrence of deform- 
ity does not, as a rule, occur following reduction, and accordingly 



36 FRACTURES AND DISLOCATIONS 

no retentive apparatus other than a sling and body swathe will be 
needed. 

Operative Treatment. — Open treatment is seldom indicated 
since reduction can, as a rule, be maintained by the dressings just 
described. In exceptional instances suture of the outer end of the 
clavicle to the acromion may be needed to prevent recurrence of 
deformity. Both wire and absorbable suture material have been 
successfully employed. It may be possible in some cases to suture 
the ligaments about the end of the bone in such a manner as to 
obviate the necessity of drilling into the bone. In the downward 
variet}^ of luxation operation may be called for to disengage the 
outer end of the clavicle. 

After-Treatment. — The clavicle should be watched for recurrence 
of deformity especialh' following the upward type of luxation. A 
certain amount of slipping will take place in the dressings and 
should be corrected to keep the end of the bone in position. Irrita- 
tion may develop at the site of • pressure and require attention. 
Three to four weeks should be allowed for the ligaments to heal. 

Prognosis. — The outlook in the ordinary case of luxation of the 
outer end of the clavicle is good as far as restoration of function is 
concerned. The prominence of the articulation may be a little 
greater than normal when recover}^ is complete, and in some cases 
a slight amount of displacement may persist, but these conditions 
are not incompatible with free use of the part and a strong joint. 
Downward luxations may be attended by injury to the brachial 
plexus since this displacement decreases the space between the 
clavicle and the first rib, and the prognosis will depend on the 
severity of the plexus involvement. Old unreduced luxations often 
show^ a remarkable restoration of function and the formation of a 
new joint. 



CHAPTER V. 

FRACTURES OF THE SCAPULA. 

Surgical Anatomy.— The freedom of motion in this bone and the 
fact that it is almost entirely surrounded by heavy muscles, account 
for the rarity with which it is fractured. Some portions of the 
scapula (spine and acromion process) are subcutaneous and accord- 
ingly more often injured. The acromial epiphysis usually joins 
the remainder of the bone between the eighteenth and twenty-fifth 




Figs. 46 and 47. — A^'entral and dorsal surfaces of the right clavicle. A.. Acromion 
process; C, Coracoid process; G., Glenoid cavity. 

years, although it may remain ununited throughout life. This 
condition has been mistaken for fracture. The attachments of the 
deltoid and trapezius tend to prevent displacement when this 
portion of the bone is broken. The attachment of these muscles and 
the heavy fibrous tissue surrounding the acromion and spine 
explain the difficulty of eliciting crepitus in the presence of fracture 
in this region. When, however, these structures are lacerated 

37 



38 FRACTURES AND DISLOCATIONS 

sufficiently to allow displacement, crepitus, abnormal mobility and 
deformity are recognized without difficulty. If the fracture is 
internal to the acromio-clavicular articulation we have a condition 
closely resembling dislocation of the outer end of the clavicle. 

Fracture of the coracoid is an extremely rare occurrence. It has 
been broken as the result of muscular action due to the pull of the 
short head of the biceps, coraco-brachialis and pectoralis minor. 
Epiphyseal separation of this process has been known to occur 




Fig. 48. — ^View of the same bone from the axillary border. Note the relation of the 
coracoid and acromial processes to the glenoid cavity. 

prior to the seventeenth year, at which time ossification makes it 
continuous with the rest of the bone. 

Fracture of the glenoid cavity usually results from violence 
transmitted through the head of the humerus. It may exist as a 
complication of fracture- or dislocation of the humeral head. 
Fracture of the neck of the scapula may occur from similar causes. 
The thinnest and best protected portion of the bone is the body. 
Fracture rarely occurs in this region, but when it does it is almost 
invariably the result of direct violence. The spring of the ribs 
supporting the scapula undoubtedly enables it to withstand greater 
violence, but when trauma is severe we may have fracture of the 



FRACTURES OF THE SCAPULA 



39 



underlying- ribs as ^vell as of the body of the bone. When such is 
the case, the more superficial fracture may conceal the injury to 
the ribs. Fracture of the 'body is usually transverse below the 
spine. Comminution is sometimes observed and in rare instances 




Fig. 49. — Fracture of the neck of the scapuhi. 

the line of fracture may cross the spine. The attachments of the 
infraspinatus, subscapularis, serratus magnus, rhomboid and teres 
muscles are such that pronounced displacement rarely occurs and 
palpation is difficult. 



40 FRACTURES AND DISLOCATIONS 

Symptoms. — Loss of function, and pain (which is increased on 
motion) are always present. Deep respiration causes suffering, 
though the rapid shallow breathing, characteristic of fractures of 
the ribs, is absent. The body of the scapula may be grasped as 
shown in Fig. 50 w^hen abnormal mobility and crepitus are 
elicited, completing the list of symptoms. 

Fracture of the acromion process produces localized pain, tender- 
ness, and sometimes limited mobility and crepitus. The symptoms 
vary with the position of the fracture in relation to the acromio- 
clavicular articulation. Fracture of the acromion, external to the 
acromio-clavicular joint, produces local pain and tenderness. 
Crepitus and abnormal mobility may be present on manipulation, 
but deformity is almost uniformly absent. Fracture of the 
acromion entering the articulation gives rise to symptoms 
closely resembling fracture external to the joint, though mo- 
tions of the shoulder are usually more painful. Fracture of the 
acromion internal to its articulation with the clavicle, is accom- 
panied by symptoms almost identical with dislocation of the outer 
end of the clavicle, especially if the muscular and fibrous attach- 
ments of the process have been torn sufficiently to allow deformity. 
The shoulder drops downward, forw^ard and inward, and undue 
prominence is observed at the outer end of the clavicle. Palpation 
reveals the acromial fragment attached to the outer end of the 
collar bone. Abnormal mobility of the displaced acromial frag- 
ment is present, but crepitus is absent unless the fractured surfaces 
have remained in contact. 

Fracture of the coracoid gives rise to localized pain and tender- 
ness just below the junction of the middle and outer thirds of the 
clavicle. Displacement, if present, is very slight owing to the fact 
that the rhomboid and trapezoid ligaments are seldom torn. These 
ligaments securely hold the fragment in position against the actions 
of the attached muscles. The tip of the coracoid may be palpated 
if pressure is made at the proper point below the clavicle. It is 
impossible, however, to grasp the process between the fingers, and 
for this reason it is difficult to elicit crepitus and abnormal mobility. 

Fracture of the surgical neck of the scapida gives a picture 
somewhat resembling dislocation of the shoulder, although the 
deformity is not characteristic of any type of shoulder luxation, 
and crepitus can usually be elicited by manipulation. Fracture of 
the glenoid cavity, especially a fragment from the anterior edge, 



FRACTURES OF THE SCAPULA 



41 



is a complication sometimes occurring in dislocations of the 
shoulder, and results in spontaneous recurrence of deformity fol- 
lowing reduction. Crepitus may, or may not, be present. 

Diagnosis. — A consideration of the symptoms occurring in frac- 
tures of different regions of the scapula should render the diagnosis 
in most cases eas}^ Fracture of the acromion and body are by far 
the most common injuries seen in this bone. Fracture of the 
surgical neck may, at times, be extremely difficult to differentiate 
from dislocations of the shoulder and fractures of the upper end of 




Fig. 50, — Method of grasping the Ixidy of the scjipiihi in detect the presence of 
fracture. The fingers of the right hand are palpating the spine of the scapula. 



the humerus. Deep palpation of the axilla may detect the glenoid 
cavity moving with the head in its inward displacement. Fractures 
of the glenoid cavity, surgical neck and coracoid, may require the 
use of the X-ray before diagnosis can be established. The fre- 
quency with which radiography reveals unsuspected conditions in 
and about the shoulder demonstrates the value of the X-ray as a 
routine measure in injuries of this region. The difficulty of 
diagnosis is greatly increased if the case is not seen for tw^enty-four 
or forty-eight hours following the accident. By this time the 
swelling and tenderness have so increased that less is learned 
from inspection or palpation, and manipulation of the parts is 
seriously objected to by the patient. An anesthetic is often neces- 



42 FRACTURES AND DISLOCATIONS 

sary to determine the condition, especially if the X-ray is not 
available. 

Treatment. — The treatment must, of necessity, vary with the 
region and function of the portion of the bone injured. Fracture 
of the body of the bone calls for strapping of the chest in such a 
manner that the scapula will be immobilized. In addition the arm 
should be fixed to the side of the chest by a swathe or additional 
strapping. The Yelpeau bandage may be used to advantage, 
especially when reinforced with starch or plaster of Paris. Oppos- 
ing surfaces of skin should be protected by the interpoiition of some 




Fig. 51. — Oblique strapping with adliebive planter to immobilize the body of the 
scapula. 

absorbent material, such as cotton. In fracture of the acromial 
process, especially with displacement, the indications in treatment 
are similar to those of fracture of the clavicle. A Sayre's dressing, 
or modification, such as shown on page 24, will answer the purpose 
satisfactorily. Additional pressure directly over the fragment may 
be had by means of a strap of adhesive and pad of gauze appro- 
priately placed. In fracture of the coracoid process direct immo- 
bilization of the fragment "is hardly possible, yet the arm should be 
so fixed to the side as to prevent action of the three muscles attached 
to the process. The indications in the treatment of fractures of 
the surgical neck of the scapula are similar to those of fracture of 
the upper end of the humerus. The axillarj^ pad and plaster of 
Paris shoulder cap can, as a rule, be so applied that the fragment 
is held in proper reduction. (See Fig's. 132 to 140.) It is 



FRACTURES OF THE SCAPULA 43 

nsiially unwise to allow use of the forearm or hand in fractures of 
any portion of the scapula. In the less severe conditions the arm 
should at least be carried in a sling, while the remainder of the 
upper extremity is securely immobilized. 

After-Treatment. — Union will usually take place within a month. 
AYhen fracture occurs in parts of the scapula which are subject to 
considerable strain, such as the neck of the bone or the acromion, 
internal to its articulation with the clavicle, immobilization should 
be maintained for about two weeks longer. The dressings should 
be carefully inspected daily for the first week to avoid loosening 
and slipping. If irritation of the skin occurs it should receive 
proper attention. 

Prognosis. — Fractures of the body of the scapula seldom produce 
permanent impairment of function. Fractures of the surgical 
neck, and of the acromion w-ith displacement, may be followed by 
some loss of function, if not properly reduced. Perfect function 
is likelv to follow fibrous union of the coracoid. 



CHAPTER VI. 

DISLOCATIONS OF THE SHOULDER. 

Surgical Anatomy. — The peculiar construction of the shoulder 
joint, its wide range of motion and exposed position, result in its 
being the most common site of dislocation in the hody. 

The articulation is typical of the ball and socket joint. The 
bones entering into its formation are the head of the humerus and 
the glenoid cavity of the scapula. The acromion and coracoid 
processes, with the coraco-acromial ligament stretching between 
them, are not considered a part of the joint proper, yet they play 
an important part in preventing upward displacement of the 
humeral head. The wide range of motion possible in this joint is 
the result of the disproportion in the sizes of the articular surfaces 
of the humeral head and glenoid cavity. Extreme mobility 
renders the upper extremity more serviceable in many ways, but 
on the other hand it is evident that this type of joint construction 
is dependent almost entirely on ligaments and muscles for its 
stability. The coraco-acromial and capsular are the only ligaments 
of surgical importance in the shoulder joint. The coraco-acromial 
ligament arches over the head of the humerus, filling in the space 
between the two processes and serves to prevent upward displace- 
ment of the humerus. The capsular ligament entirely surrounds 
the articulation, being attached to the rim of the glenoid cavity 
just beyond the glenoid ligament, and externally to the anatomical 
neck of the humerus. This ligament is much too lax on all sides 
to keep the articular surfaces in contact, but this very laxity is 
necessary to allow the freedom of motion which this joint enjoys. 
A portion of the capsule becomes taut only w^hen the arm is carried 
to the extreme limit of motion in a given direction. (See Figs. 
52 and 53.) Some portions of the capsule are more subject to 
strain than others, and accordingly we find such parts reinforced 
by muscle tendons or thickenings in the capsule itself. These 
thickenings have been given special names, such as the coraco- 
humeral in the upper part of the joint, and the ligaments of Flood 

44 



DISLOCATIONS OF THE SHOULDER 



45 



and Schlemm anteriorly. The transverse humeral ligament serves 
to confine the long tendon of the biceps within the bicipital groove, 
and the glenoid ligament forms a margin around the glenoid cavity, 
increasing its depth. The ligaments surrounding the joint prevent 
dislocation by limiting the range of motion, while the muscles, by 
their tonicity, actively hold the articular surfaces in apposition. 
The deltoid arising from the clavicle, acromion and spine of the 
scapula keeps the humerus well up in place against the under sur- 
face of the arch made by the coracoid, coraco-acromial ligament 
and acromion. Paralysis of this muscle results in a dropping of 




Fiss. 52 and 53. — Diagrams illustrating the action of the capsule in different posi- 
tions of the joint. It is apparent that it must be lax enough on all sides to allow 
motion of the humerus in different directions and that its function is to limit motion and 
not to hold the humeral head firmly against the glenoid cavity. 

the humerus with separation of the articular surfaces in the 
shoulder joint. The tendon of the long head of the biceps 
strengthens the upper part of the capsule, keeps the head of the 
humerus in proper apposition with the glenoid during the various 
movements of the arm and prevents the head from being pulled too 
closely upward under the acromion. The action of the coraco- 
brachialis is similar to that of the deltoid in holding the humerus 
up. The tendon of the subscapularis reinforces the capsule, and 
in the anterior dislocations is not infrequently torn when this 
particular portion of the capsule is penetrated by the head. The 
tendons of the supraspinatus, infraspinatus and teres minor rein- 
force the capsule and aid in maintaining the proper relations of 



46 FRACTURES AND DISLOCATIONS 

the articnlar surfaces. The brachial plexus and axillary artery 
occupy a position internal to the head as they descend through the 
axilla, and may be injured in dislocations of the shoulder. In the 
forward and downward types of luxation direct pressure may be 
made on these structures by the humeral head; the pulsating axil- 
larj' artery may often be palpated as it stretches across the head in 
subglenoid luxations. The injuries sustained by the structures 
about the joint depend on the direction taken by the head as it 
leaves the glenoid and the degree of violence producing the luxa- 
tion. The planes of least resistance about the joint lie between the 
muscles rather than through them, though naturally the greater the 
violence producing the dislocation the greater the probability of a 
muscle being penetrated by the head. The subscapularis is the 
muscle most frequently penetrated in this manner. 

The capsular ligament is practically always torn at the point 
-where the head leaves the glenoid fossa and, since the common dis- 
placements are of the anterior variety, the rent wdll usually be 
found in the antero-inferior portion of the capsule. A few cases 
of anterior luxation without injury to the capsule have been 
reported in which the joint was previously much relaxed and the 
capsule unusually roomy. Injury to the capsule is not infrequently 
accompanied by injury to the tendons which overlie and reenforce it 
and, when the violence producing the luxation is great, there may 
be a destiniction of tendon continuity. 

The trauma causing the luxation may at the same time produce 
a fracture of the glenoid cavity or of the upper end of the humerus. 
The anterior rim of the glenoid may be broken off by the head of 
the humerus as the articular surfaces are forced past each other. 
The head and tuberosities maj^ suffer a variety of fractures which 
are so diverse that two cases are rarely seen alike. The greater 
tuberosity is sometimes found parted from the shaft and displaced 
in the line of the pull of the muscles attached to it. This frag- 
ment may lie in the glenoid cavity where it offers obstruction to 
reduction. Fractures of the surgical neck, with or without dislo- 
cation of the shoulder, are more constant in type than fractures of 
the anatomical neck. Fracture of the anatomical neck, especially 
when complicated by dislocation, is sometimes represented by a 
comminuted, crushed condition of the upper end of the humerus, 
in which the lines of fracture are extremely variable. The cap of 
bone represented by the articular surface is usually less com- 



DISLOCATIONS OF THE SHOULDER 



47 



minuted than either the underlying structure or the tuberosities. 

Fracture of the upper end of the humerus more often occurs 

in those cases of dislocation which have been produced by direct 




Fig. 55 

Fig. 54. — Normal shoulder. CL, clavicle: C, coracoid process; A 
ess; G., glenoid cavity; H.H., humeral head; H.S., humeral shaft. 
Fig. 55. — Subcoracoid dislocation. 



acromion proc- 




Fig. 56. — Intracoracoid or subclavicular dislocation. Ci., clavicle; ('., coracoid proc- 
ess; A., acromion process; 6'., glenoid cavity; H.R., humeral head; 7/.^'., humeral shaft. 
Fig. 57. — Intraclavicular dislocation vs^ith moderate deformity. 

violence, the blow haying been sustained on the outer side of the 
shoulder just below the acromion. 



48 



FRACTURES AND DISLOCATIONS 



Separation of the lesser tuberosity has been noted as a compli- 
cation of dislocation of the shoulder, though it is much rarer than 
fracture of the necks or greater tuberosity. 

The most important structures which may be injured by the 




Fig. 58. 



Fig. 59. 



Fig. 58. — Subglenoid dislocation. CI., clavicle; C, coracoid process; A., acromioi 
process; G., glenoid cavity; H.H., hnmeral head; H.S., humeral shaft. 
Fig. 59. — Luxatio erecta. A variation of the subglenoid type. 




Fig, 60. 



Fig. 61. 



Hnn«"^''^h-^f?''~;;^'^''"iT'^l^'^i?o^*'u''- ^¥ ^^^^ pronounced of the two posterior luxa- 
scapula ^iimeral head; H.S., humeral shaft; A., acromion process; ^..S-., spine of 

Fig. 6i;— Subspinous dislocation. An exaggeration of the subacromial type. 



DISLOCATIONS OF THE SHOULDER 49 

displaced head are the brachial plexus and axillary artery which 
lie just internal to it in the axilla. When the artery is torn hemor- 
rhage into the axilla will follow, while simple pressure on the vessel 
will only temporarily interfere with the pulse in the arm below. 
Pressure on the brachial plexus may result in partial or complete 
paralysis of the parts supplied by it. The exact mechanism of 
injury to the brachial plexus is not thoroughly understood; some 
writers consider it a result of direct pressure on the nerves by the 
head or neck of the bone, while others are of the opinion that the 
stretching sustained by the plexus is the usual method of injury. 
In any case this complication is fortunately rare, and the resulting 
paralysis usually transient. There is little doubt that the plexus 
may be injured in attempts at reduction, especially when the older 
method of using a fulcrum in the axilla is resorted to. Permanent 
injury to the artery is seldom seen ; as a rule we may look for 
nothing more than a temporary suspension of circulation below 
the point of pressure, during the time the head is out. When the 
dislocation is allowed to remain unreduced for a few weeks fibrous 
tissue is formed about the head, which will ultimately make a new 
socket, and in many instances we see remarkable restoration of 
function. The usefulness of the joint, however, can never be 
expected to approach the normal under such circumstances. 

The head of the humerus may pass from the glenoid in almost any 
direction, and this fact has given rise to a variety of classifications 
which in many instances have but served to confuse rather than 
help us to a clearer understanding of the subject. The simplest 
classification will be used here : 

•^ Subcoracoid 

/Subclavicular (or intracoracoid) 



Downward 
Backward 



/Subglenoid 

^Subglenoid erect (Luxatio erecta) 



r Subacromial 
I Subspinous 

Upward (very rare) 



By far the most frequent dislocation of the shoulder is forward, 
and of the two sub varieties the subcoracoid is much more common. 
The subglenoid is next in order of frequency, while the erect type 
is more uncommon than either of the posterior varieties. 



50 FRACTURES AND DISLOCATIONS 

In the suhcoracoid type the head lies below the coracoid process, 
having escaped through the antero-inferior portion of the capsule. 
The line to be drawn between this luxation and the subclavicular 
variety is purel}^ artificial and arbitrary. If more than three- 
fourths of the transverse diameter of the humeral head lie internal 
to the coracoid the luxation is known as subclavicular. More or 
less inward rotation of the humerus is present. The tendon of 




Fig. 62. — Outlined X-ray of a low sxibcoracoid dislocation of shoulder. 

the subscapularis is not infrequently torn, and in rare instances 
injury may be sustained by the supraspinatus, infraspinatus or 
teres muscles. Tearing of the coraco-humeral ligaments practically 
never occurs in this type of luxation. The head of the bone often 
lies on the anterior edge of the glenoid cavity. 

In the subclavicular type the head continues inward, clears the 
coracoid process and rises to a slightly higher level. The tearing 
of the capsular ligament is usually more severe than in the suh- 
coracoid form and rupture of the tendons inserted into the upper 
end of the humerus is more common. The coraco-humeral liga- 



DISLOCATIONS OF THE SHOULDER 51 

meiit is often extensively torn and accordingly Kocher's method 
of reduction will fail. 

SuhgJowid luxations. — In the typical subglenoid dislocation the 
head of the bone lies below the glenoid cavity. There is no hard 
and fast line to be drawn between the subcoracoid and subglenoid 
varieties, since in practice we find the head may occupy a position 
anywhere along the anterior rim of the glenoid cavity. 

In the erect type of subglenoid luxation (luxatio erecta) the head 
lies below the glenoid but the arm is in a position of extreme 
abduction. 

In the subacromial type the head of the bone lies behind the 
glenoid cavitj^ just under cover of the acromion. The rent is in 
the posterior portion of the capsule. The biceps tendon may be 
torn out of its groove and the bellies or tendons of the muscles 
inserted into the greater tuberosity (especially the infraspinatus) 
may be extensively torn. Complicating fracture of the greater 
tuberosity is more common in this type of luxation than in the 
subcoracoid form. The tendon of the subscapularis may be torn 
from its insertion into the lesser tuberosity. 

The subspinous form is an exaggeration of the subacromial, in 
which the head continues in its backward course till it lies in the 
infraspinous fossa just below the spine of the scapula. The vio- 
lence producing this form is great and it is usually only a short 
time following the accident until the surrounding tissues and skin 
covering the head are filled with ecchymotic blood. Injury to 
surrounding muscles and ligaments is usually more extensive than 
in the subacromial type. 

The upward variety is only possible when the acromion has been 
fractured, and is so extremely rare that it might better be consid- 
ered a surgical curiosity. 

There is no hard and fast line to be drawn between the subcora- 
coid and subglenoid varieties since in practice we find the humeral 
head may occupy positions at different levels anywhere along the 
anterior rim of the glenoid cavity. This fact is demonstrated 
by the accompanying photographs and Rontgenograms. In like 
manner the subcoracoid luxation merges into the subclavicular 
type. 

Etiology. — This is the most common dislocation in the entire 
body. It occurs most frequently in adult life and results from 
various types of trauma applied to the shoulder. The most com- 



52 



FRACTURES AND DISLOCATIONS 



mon form of luxation is usually produced b}^ violence applied to 
the shoulder when the arm is in extreme abduction. 

Symptoms.— Immediately following the accident the patient 
suffers severe, acute, nauseating pain which is increased by motion 
of the affected shoulder. Loss of function is produced by the 
inhibitory effect of pain, by the reflex spasm of the muscles and by 




Fig. 63. — Recent subcoracoid dislocation of left shoulder. Note the flattened shoul- 
der as indicated by the arrow, the change in the axis of the humerus and the lower- 
ing of the axillary fold. This picture is quite typical of the subcoracoid form of luxa- 
tion. It will be noted that the patient makes no attempt to support the injured member 
as is commonly done in fractures of the clavicle or humerus, especially the latter. 



the mechanical disturbance in the joint. If the luxation is allowed 
to go uncorrected the first two conditions grow gradually less while 
the last named persists and results in permanent disability. The 
nature of the deformity will depend on the type of luxation. 

In the siCbcoracoid variety there is a flattening of the shoulder 
which when palpated, as shown in Fig. 65, allows the examining 
fingers to pass inward under the acromion process. The upper 
end of the humerus is displaced inward and the axis of the arm 



DISLOCATIONS OF THE SHOULDER 



53 




Fig. 64. — Simple subcoracoid dislocation of left shoulder presenting the usual 
symptoms : flattening of the shoulder, change in axis of arm and lowering of the 
axillary fold. 




Fig. 65. — Examining depression below the shoulder. Note how, with moderate 
pressure, the fingers sink in below the acromion. Photograph taken just after the 
accident and immediately prior to reduction by Kocher's method. 



54 



FRACTURES AND DISLOCATIONS 



is altered. This change in the axis of the humerus may be recog- 
nized at a glance. The humeral head rests beneath the tip of the 
coracoid process and occupies a slightly lower position than normal. 
Lowering of the humerus as a whole lowers the attachment of the 
pectoralis major and accordingly the anterior axillary fold will be 
lower on the injured side. An abnormal prominence will be noted 
below the coracoid where the head has found its new resting 
place. The elbow seldom lies in contact with the side of the chest 




Fig. 6 I . 



Figs. 66 and 67. — Lateral and anterior views of a subcoracoid luxation of right 
shoulder. This shoulder has been dislocated eight times, the first luxation being about 
ten years ago. The manner in which the fibres of the deltoid pass in straight lines 
from the acromion to their insertion indicates the absence of the head of the humerus 
from the glenoid cavity. Reduction accomplished by Kocher's method with the patient 
in the sitting position. 

and any attempt at adduction will meet with resistance and cause 
additional pain. Abduction will bring out the lines of the already 
prominent acromion, accentuate the flattening of the shoulder and 
is not specially productive of resistance and pain. It is difficult 
to place the hand of the injured side on the opposite shoulder and 
when this has been accomplished it will be found impossible to keep 
the elbow in contact with the chest. This symptom is character- 
istic of anterior luxations and is the result of the head being "off 
center." A simple though unnecessary test is to place a ruler on 
the outer side of the arm; it will be noted that the ruler can be 
placed in contact with the acromion and external epicondyle simul- 



DISLOCATIONS OF THE SHOULDER 



55 




Fig. 68. — Another view of the same case showing the position of the humeral head 
as indicated by palpation. The head lies between the two fingers on the shoulder. 




Fig. 69. 



Fig. 70. 



Figs. 69 and 70. — Another subcoracoid dislocation of the shoulder presenting the 
usual symptoms. In this case the head of the humerus occupies a slightly lower posi- 
tion than seen in the cases shown on the preceding pages. The slight deltoid angle 
present is the result of this lower position of the head. The change in the humeral axis, 
flattening of the shoulder, lowering of the axillary fold and "deltoid angle" are all more 
pronounced than seen in the typical subcoracoid luxation. This is due to fact that the 
head of the bone is lower and the dislocation assumes slightly the characteristics of the 
subglenoid type. 



56 



FRACTURES AND DISLOCATIONS 




pig_ 7i_ — An anterior dislocation of the shoulder about half-way between the sub- 
coracoid and subglenoid types. Compare this case Avith those shown in Figs. 63, 64, 
67. 75 and 77. 




Fig. 73. 



Figs. 72 and 73. — Anterior dislocation of the right shoulder with the head occu- 
pying a slightly lower position than that seen in the preceding case (Fig. 71). This 
case might properly be termed a high subglenoid luxation. The empty glenoid is well 
indicated by the straight lines of the deltoid muscle and the prominence of the cora- 
coid process with its attached muscles. The thumb pressed into the shoulder lies di- 
rectly above the displaced head. Note how closely this case resembles the t}i)ical sub- 
glenoid luxation shown in Fig. 77. 



DISLOCATIONS OF THE SHOUT^DER 



57 



taueoiisly, which is impossible in the normal shoulder. The head 
of the bone maj' be palpated in its new position in the axilla. 
Slight abduction of the arm facilitates this portion of the exam- 
ination. The head may also be palpated through the deltoid and 
pectoralis major as shown in P^'ig. 68. 

The patient's attitude is characteristic. In standing the body 
is inclined slightly forward and toward the injured side. This 
position is assumed so the displaced humeral axis may be brought 
more nearly to the vertical. There is very seldom any attempt 
made to support the injured member but instead it hangs limp from 




Fig. 74. 



Fig. 75. 



Fig. 74. — Subglenoid dislocation of right shoulder. The head of the humerus lies 
below the palpating finger. While plowing the share struck a rock and the handles of 
the implement v.-ere thrown violently upward and the right shoulder dislocated. 

Fig. 75. — Same case. The head of the humerus lies between the two index fingers. 
The brachial plexus and pulsating axillary artery can be felt stretched across the head 
by the fingers palpating in the axilla. 



the shoulder. In the sitting position the arm is rested on some 
convenient object such as a table, or the arm of a chair. In the 
typical subcoracoid luxation the elbow is close to, but not in contact 
with, the side. "When the head occupies a lower position on the 
anterior rim of the glenoid abduction of the arm will be more pro- 
nounced. 

In the suh clavicular or intracoracoid type the shoulder is flatter 
and the prominence below the clavicle, caused by the head, is nearer 
the median line. After the head clears the coracoid in its inward 
course it rises to a higher level, and thus the whole humerus 
occupies a higher position than that seen in the subcoracoid type. 



58 FRACTURES AND DISLOCATIONS 

The level of the anterior axillary fold is variable. The deformity 
depends somewhat on the completeness of rupture of the coraco- 
humeral ligament. If this ligament is completelj^ ruptured the 
arm is usually closely applied to the chest wall. If it is only 
partially ruptured abduction of the arm may be pronounced even 
to the extent of being held in a nearly horizontal position. It may 
be possible to palpate the empty glenoid cavity. The arm usually 
shows more or less shortening which is accentuated by abduction. 
When the coraco-humeral ligament is completely ruptured the 
head may occupy an unusually low position beneath the clavicle. 




Fig-. 76. — Same ease after luxation had been reduced. Arm bandaged and fixed to 
side by strip of adhesive encircling the chest. 

In the subglenoid variety the humeral head rests on the long 
head of the triceps below the glenoid cavity, though this position 
is occupied only in the most pronounced cases. All the symptoms 
noted in the subcoracoid type are present in exaggerated form in 
the subglenoid variety. The arm is lengthened, the axillary fold 
much lowered, the axis of the humerus pronouncedly altered and 
abduction of the arm is a prominent symptom. The. lowering of 
the humerus is greater in this form than in any other type of luxa- 
tion occurring at the shoulder joint. The outer side of the arm 
forms an angle (''deltoid angle") with the insertion of the deltoid 
as the apex. This angle is the result of abduction and indicates 
the low position of the head. 



DISLOCATIONS OF THE SHOULDER 



59 




Fig. 77. — A typical subglenoid dislocation of the left shoulder. Flattening of the 
shoulder, lowering of the axillary fold and change in the humeral axis are much more 
pronounced than in the snhcoracoid type. In the subcoracoid type the outer surface of 
the arm is approximately a straight line but in this case it will be noted that a distinct 
angle is formed which for convenience has been termed the "deltoid angle." The apex 
of the angle is indicated by the arrow. The upper arm of the angle extends to the 
acromion while the lower arm extends to the external epicondyle. The lower the posi- 
tion occupied by the luxated head the more pronounced will this angle be. 





Fig. 78. 

Fig. 78. — Typical subglenoid dislocation of left shoulder. 

Fig. 79. — Attitude assumed by patient since it is accompanied by less pain than an;, 
other position. .This attitude is not especially uncommon in subglenoid luxations. 



60 



FRACTURES AND DISLOCATIONS 



Compare the clinical appearance of the cases shown in the accom- 
panying illustrations. Fig. 11 shows a typical subglenoid luxa- 
tion. Fig. 72 shows a higher form while Fig. 69 shows what 
might be termed a low subcoracoid. 



Fig. 80. — Subglenoid luxation 
Fig. 79. 




one seen in 



Fig. 81. — Another view of patient shown in Fig. 80. 



In the erect type of subglenoid luxation (luxatio erecta) the 
shoulder is dislocated while the arm is in extreme abduction and the 



DISLOCATIONS OF THE SHOULDER 



61 



head comes to rest at the lowest possible point, being in some cases 
even caught under the long head of the triceps. The attitude is 
characteristic; the arm is raised and the hand usually rests on the 




Fig. 82. — Luxatio erecta. Patient was hit by a train and sustained numerous in- 
juries, among; them the one shown here. Extension in the altered axis of the arm. and 
direct pressure on the head accomplished reduction without difficulty. Two days later 
the patient died as a result of associated injuries and immediately following death the 
dislocation was reproduced, the upper extremity placed in the same position as when 
first seen and the photograph taken. It was not feasible to take a picture when the 
patient was first seen but the position and appearance of the extremity as shown here 
are the same as existed immediately following the accident. 




Fig. 83. — Another view of patient shown in Fi 



82. 



top of the head. The patient is unable to adduct the arm and the 
head may be seen as well as felt in the axilla. The condition is 
really a subglenoid luxation but the appearance of the patient is 
quite different from the usual subglenoid. 



62 



FRACTURES AND DISLOCATIONS 



In the siibacroynial hjpe the head lies behind the glenoid, having 
been driven across its posterior lip. The anterior portion of the 
anatomical neck rests on the posterior edge of the glenoid and the 
articular surface looks into the infraspinous fossa. A prominence 
will be noted on the posterior aspect of the shoulder while anteriorly 
the shoulder will be flattened and the acromion prominent. The 
arm is usually shortened and more or less fixed with the elbow 
forward. (See Figs. 84 and 85.) 




Fig. 84. — Posterior dislocation of right shoulder. The humeral head projecting on 
the posterior aspect of the shoulder is plainly visible. Note shortening of arm and 
change in axis. 

Fig. 85. — Palpation of displaced head. Its position is outlined by the two index 
fingers and thumbs. 



The sutspinous type is simply an exaggeration of the preceding. 
The head is driven further backward on the posterior surface of 
the scapula till it comes to rest under the spine of the bone. This 
form is very rare and is usually the result of great violence. The 
symptoms of the subspinous type are those of the subacromial in 
pronounced form. The arm is shortened, moderately abducted, 
rotated inward and the elbow on a plane anterior to the chest. The 
trauma of the head plowing through the tissues causes more or less 
extravasation of blood and it is usually only a short time following 
the accident until the skin covering the head of the bone becomes 
ecchymotic. The further the head passes backward under the 



DISLOCATIONS OF THE SHOULDER 



63 




Fig. 86. — Another view of the case shown in Figs. 84 and 8c 




Fig. 87. — Case of complete avulsion of the vipper extremity. Case reported b? 
cause it indicates to some extent the weakest points in the various structures which hold 
the shoulder together. Capsule torn cleanly from the anatomical neck except over the 
greater tuberosity where a triangular piece with a base equal to the breadth of the 
tuberosity and about thi-ee-quarters of an inch to the apex. Supra- and infra-spinatous 
muscles have been torn from the tuberosity and scales of bone corresponding to the 
insertions of the tendons have been detached. Tendon of teres minor torn across about 
two inches from its insertion. Stibscapularis torn cleanly from lesser tuberosity. Small 
shreds of the pectoralis major remain attached to the external bicipital ridge, large shred 
of lower portion of this muscle (about three inches long) remains attached to humerus. 
Teres major and latissimus dorsi torn cleanly from hvimerus. Long head of biceps 
torn near origin. Short head torn a little below the point at which the tendon joins the 
belly. About two inches of the coraco-brachialis remains attached to the humerus 
(transverse tear through muscular tissue). Long or middle head of triceps torn 
transversely below tendon, at about level of the surgical neck. Median and ulnar 
nerves torn at level of surgical neck. Deltoid torn loose from clavicular and scapular 
origins with the exception of the portion arising from the acromion. The acromion is 
fractured transversely about three-quarters of an inch from the tip, the fragment re- 
maining attached to the deltoid. Insertion of deltoid torn cleanly from humerus leav- 
ing deltoid eminence free from shreds. Compound comminuted fracture of radius and 
ulna, and backward dislocation of wrist. (The wrist was reduced before the picture 
was taken.) Injury sustained in centrifugal wringer in laundry. The patient recovered. 



64 



FRACTURES AND DISLOCATIONS 



spine of the scapula the more liable the arm is to be fixed in its 
new axis. 

In the extremely rare upward luxation the arm is shortened, the 
acromion fractured and the anterior axillary fold raised. The 
head of the bone may be felt as a prominence at the point of the 
shoulder and crepitus is present if the fragment of the acromion is 
manipulated. 



ir^-"-^ 




Fig. 88. — Example of a subcoracoid dislocation in a fleshy woman. The symptoms 
in obese persons are somewhat obscured by the adipose tissue and the condition has not 
infrequently been overlooked under these circumstances. If the case is carefully in- 
spected, however, there should be no reason for failure in diagnosis. 

Diagnosis. — There is a good deal of difference in the deformities 
of the different types of luxation occurring at the shoulder yet 
each is characteristic in its way, and if the surgeon is acquainted 
with the appearance of these deformities there should seldom be 
any difficulty in recognizing the condition. There is a nice pro- 
portion existing between the various symptoms in an ordinary sub- 
coracoid or subglenoid luxation and it is of value for the surgeon 
to recognize this fact. A given amount of flattening of the 
shoulder usually goes with a certain degree of change in the 
humeral axis and lowering of the axillary fold. This relation 
between the different objective symptoms can best be appreciated 



DISLOCATIONS OF THE SHOULDER 



65 



by comparing' the accompanying illnstrations. (Figs. 63 to 77.) 
These symptoms bear an almost constant relation to each other in 
simple luxations, but this relation is frequently disturbed when 
fracture is present. In Fig. 96 flattening of the shoulder is shown 
without any change in the axis of the humerus. The condition is 
one of fracture of the anatomical neck with dislocation of the head 




Fig. 89. — Another example of the same condition as shown in preceding illustra- 
tiou. The patient is excessively heavy yet the flattening of the shoulder, change in 
hnmeral axis and lowering of the axillary fold are sufficiently pronounced to recognize 
the condition by inspection alone. 



of the bone. In Figs. 117 and 118 the change in the axis of the 
humerus is apparent but there is no flattening of the shoulder. 
The condition is one of fracture of the surgical neck. 

Nearly all the objective symptoms are less pronounced, in fleshy 
persons, yet this fact should be no excuse for failure to diagnose 
the condition when present. (See Figs. 88 and 89.) In luxa- 
tions of the shoulder the patient seldom makes any attempt to 
support the injured member with the opposite hand but allows the 
upper extremity to hang limp at the side with a slight inclination 
of the trunk forward and to the same side. In the exceptional 
cases in which he does support the arm the act is casual and he 
will usually release it if requested. This is quite different from 
the attitude assumed by the patient in the presence of fracture of 
the humerus. He will then grasp and support the injured member 



66 FRACTURES AND DISLOCATIONS 

with the greatest care and anxiety, and can seldom be induced to 
release it when in the standing or sitting position. 

The diagnosis must be made on the symptoms, and relief afforded 
the patient at once. The X-ray is therefore seldom of value except 
in verifying reduction and in the exclusion of complicating frac- 
tures, after the head has been returned to the glenoid cavity. 

Treatment. — In all forms of luxation the indications are to 
return the head to the glenoid cavity at the earliest possible 
moment and to maintain the parts at rest until the torn ligaments 
are healed. The methods of reduction vary with the type of 
luxation. 

The suhcoracoid luxation is best reduced by what is known as 
Kocher's method, which consists of three steps and is as follows: 
"With the patient seated in a straight, armless chair the surgeon 
grasps the elbow with his opposite hand. The elbow is then held 
firmly against the side while the free hand secures the wrist, brings 
the forearm to a right angle and then carries it outward away from 
the median plane. This produces outward rotation of the humerus 
and opens the rent in the capsule. (See Fig. 91.) 

The second step in the manipulation consists in gently forcing 
the elbow forward and inward across the chest Avhile the patient's 
hand is maintained in a relatively stationary position. (See Fig. 
92.) Resistance is here often encountered and should be met by 
an insistent springing motion in the direction indicated by the 
arrow in Fig. 94. It is during this second step that the head of 
the humerus usually slips back into the socket with a distinct snap. 
When Kocher's method fails it is usually due to the fact that the 
surgeon is not maintaining outward rotation of the arm during 
the time the elbow is being brought forward across the chest. In 
other words the common fault is in allowing the hand to come 
forward and inward at the same time that the elbow is being carried 
across the chest. If reduction is not accomplished during the 
second step the head is almost sure to remain displaced during the 
third, and the whole manipulation will have to be repeated. 

The third step consists in carrying the hand to the opposite 
shoulder but is not an essential part of the manipulation. Figs. 
91, 92 and 93 not only demonstrate the proper steps and positions of 
the upper extremity in performing Kocher's method but actually 
show the reduction of a subcoracoid luxation done before the 
camera. A study of these plates will give the reader a better 



DISLOCATIONS OF THE SHOULDER 



67 





Fi-. 91. 





Fig. 92. 

Demoustration of Koclier's method on a case of subcoracoid dislocation of the right 
shoulder. Case presented for treatment immediately following the accident with the 
usual characteristic symptoms. 

Fig. 90. — Appearance of case after being stripped to waist to facilitate examination 
and reduction. 

Fig. 91. — First step in Kocher's method. Head is still displaced as evidenced by 
the contour of the shoulder. 

Fig. 92. — Second step in Kocher's method. (See text.) Note the rounded contour 
of the shoulder : the head has just been returned to the glenoid. 

Fig. 93. — Third step of Kocher's method. Hand is carried to opposite side of chest. 



68 FRACTURES AND DISLOCATIONS 

idea of the manipulation than could be conveyed by pages of 
text. 

Many surgeons prefer the recumbent position in performing 
Kocher's method and in some respects it is more convenient. 

Not infrequently the patient hinders the surgeon by a sort of 
squirming motion in which he arches the body toward the injured 
shoulder and may even slide off the table away from the operator. 
This may be avoided by passing a large towel or sheet about the 
chest and under the dislocated shoulder. The ends lie in front 




Fig. 94. — This plate shows the essential action in Kocher's method. The patient's 
elbow should be carried in the direction indicated by arrow CD. while the point A. re- 
mains stationary or is carried slightly away from the median plane. Resistance is 
usually encountered and should be met by an insistent, springing motion in the direction 
indicated by the arrow. If the head of the humerus does not return to the socket dur- 
ing this stage of the manipulation Kocher's method will probably have to be repeated 
from the beginning. When the capsule has been so extensively torn that no resistance 
is encountered in carrying the elbow inward Kocher's method will prove useless and 
reduction will have to be accomplished by horizontal traction and direct pressure with 
the finger tips on the head of the humerus. 

of and behind the opposite shoulder and are used by an assistant 
in steadying the patient. If a slit be made in a folded sheet and 
the injured arm passed through it we will have an efficient means 
of steadying the patient and preventing motion of the scapula. 

If Kocher's method is properly employed it should be possible, 
in the usual uncomplicated subcoracoid luxation, to accomplish 
reduction at the first attempt and without the aid of an anesthetic. 



DISLOCATIONS OP THE SHOULDER 69 

The efficiency of Kocher's method depends on the integrity of the 
capsule, especially that portion known as the coraco-humeral liga- 
ment, and when this has been extensively torn the following method 
will generally succeed. 

Horizontal extension and manipulation. — Raise the arm laterally 
until it reaches the level of the shoulder, grasp the humerus just 
above the elbow and exercise traction while an assistant holds the 
patient about the chest. Place the opposite hand in the axilla, 
make gentle pressure on the head with the finger tips in the direc- 
tion of the socket and the luxation will be reduced provided the 
capsule and coraco-humeral ligament are extensively torn. The 
lower the head rests on the anterior rim of the glenoid the greater 
the probability of this method succeeding after Kocher's method 
has failed. A slight rotary motion of the humerus on its axis 
during traction will sometimes facilitate replacement. This method 
will sometimes effect reduction when a displaced tendon of the 
biceps or detached tuberosity has caused Kocher's method to fail. 

Stimson^s method is effective though not extensively used. It 
requires a certain amount of apparatus and time for its accomplish- 
ment. The patient is placed on a canvas cot and the arm passed 
through a slit previously made in the canvas. A weight of about 
ten pounds is attached to the wrist. Stimson claims an average 
of about six minutes for reduction, during which time the patient 
is fairly comfortable. This method may be tried as a last resort 
before operating in otherwise irreducible cases. 

Extension outward and downward. — This method is probably 
the oldest known and has been in use extensively in England and 
America up to recent years. Place the patient in a recumbent 
position and abduct the arm until it occupies an angle of about 
forty-five degrees with the body; then make traction in the long 
axis of the humerus while the body is secured by an assistant. The 
arm may be rotated during traction. It has been customary for 
years to supplement the above by placing the unbooted heel in the 
axilla as a fulcrum ; when this was done additional force was gained 
by bringing the patient's hand toward the median plane, thus 
forcing the upper end of the lever outward toward the glenoid. 
The use of the heel or any other hard body in the axilla as a fulcrum 
cannot be too strongly condemned; such methods should be dis- 
carded as a relic of barbarism for they have outlived their useful- 
ness. No pressure in the axilla should be used, which is greater 



70 FRACTURES AND DISLOCATIONS 

than can be exerted by the finger tips of the surgeon, and even then 
direct pressure on the nerves or vessels should be avoided. 

Traction outward and upward is practically the same as hori- 
zontal traction, since elevation of the arm above the horizontal is 
accomplished by rotation of the scapula rather than by alteration 
in the anatomical relations of the shoulder joint. 

Great force was advocated hy some of the older writers. Duplay 
employed horizontal traction by means of an elaborate system of 
block and tackle, dynamometer, etc. At the present time there is 
no excuse for the employment of such force. Cases which do not 
respond to the less violent and more rational methods should be 
treated by open incision. 

Subglenoid dislocations of the shoulder can usually be reduced 
by Kocher's method though the position of the head below the 
glenoid is not as favorable for reduction as it is in the subcoracoid 
form. The lower the head lies on the anterior rim of the glenoid 
the further back the elbow should be in starting the manipulation. 
In other words, the lower the head the greater the importance of 
the first step in Kocher's method. In the typical subglenoid luxa- 
tion (see Fig. 77) the elbow^ should not be further forward than 
the midaxillary line at the beginning of Kocher's method. During 
the first step the head may be caused to ride upward on the 
anterior rim of the glenoid cavity. The condition then approaches 
the subcoracoid type and can be reduced as such. (See Figs. 91, 
92 and 93.) The capsule is often extensively torn in the low sub- 
coracoid and subglenoid types and in such instances the head may 
be reduced by direct manipulation with extension and counter- 
extension. 

The erect form of the subglenoid is extremel}^ rare and the few 
cases seen by the author have been easily reduced by extension 
in the line of the axis of the displaced arm Avith digital pressure on 
the head. 

Suhacroynial and subspinous luxations are usually reduced with- 
out difficulty by traction in the axis of the arm ; axial rotation and 
manipulation may sometimes be necessary in addition to extension 
and counter-extension. The posterior forms are usually accom- 
panied by extensive laceration of the capsule, and hence their easy 
reduction. 

Following reduction the X-ray is of value in determining the 
presence of fracture and the position of the head. After the head 



DISLOCATIONS OF THE SHOULDER 71 

has been returned to the glenoid cavity the following points should 
be noted to avoid overlooking complications. Place the two arms 
by the side symmetrically and inspect the case from a point a few 
feet in front of the patient and again from the side. This is 
for the purpose of recognizing deformity. The distance between 
the acromion and external epicondyle should be carefully measured 
and compared with the uninjured side. If the distance is lessened 
it usually means complicating fracture of the humerus. If it is 
increased it commonly indicates that the head is not properly 
seated in the glenoid cavity. The anterior aspect of the two 
shoulders should be carefully compared; any undue prominence 
on the injured side suggests fracture of the upper end of the 
humerus or the interposition of some obstructing tissue between 
the head of the humerus and the glenoid. Undue prominence on 
the anterior aspect of the shoulder and shortening of the arm are 
symptoms indicative of fracture and are well shown in Figs. 119, 
12-1 and 127. 

Compare the cases of fracture of the upper end of the humerus 
with the cases of luxation of the shoulder in the accompanying 
illustrations. ]\Iotion, sensation, the condition of the reflexes and 
the circulation should be tested in the injured arm before and after 
reduction. 

The treatment of luxations of the shoulder will vary according 
to whether or not complications exist. 

In simple cases the arm should be immobilized for a period 
sufficiently long to allow proper healing of the ligaments as 
indicated in the after-treatment. (See page 79.) 

Displacement of the long head of the biceps from its groove may 
sometimes be corrected by raising the arm well forward, even above 
the horizontal and employing axial rotation. This complication, 
however, rarely occurs without fracture of the greater tuberosity, 
and under such circumstances the tendon and fragment are best 
replaced and held in position by open incision. Complicating 
fracture of the upper end of the humerus usually calls for opera- 
tive intervention to obtain the best results. 

Operative Treatment. — Operation is practically never called for 
to effect reduction of simple uncomplicated cases. It is often indi- 
cated in luxations complicated by fracture, in injury to nerves 
and vessels, in old unreduced luxations, in habitual luxations and 
in instances in which the dislocation is compound. The details of 



72 



FRACTURES AND DISLOCATIONS 



the operative procedure will depend largely on the nature of the 
complication. 

Fracture of the surgical neck of the humerus complicating luxa- 



Fig. 95. — McBurney's hook. 

tion is fortunately a rare condition, there being something like 150 
reported eases. The older method of treating this double condition 
was to either secure union of the fracture first and reduce the dislo- 




Fig. 96. — Fracture of the anatomical neck of the humerus with displacement of the 
humeral head heneath the coracoid process. The condition resembles a suhcoracoid 
dislocation of the shoulder on casual inspection. The flattening of the shoulder is the 
same as seen in dislocations (and properly so since the head is displaced) but it will 
be noted that the axis of the humerus remains unchanged and the anterior axillary fold 
is not lowered to the extent seen in uncomplicated suhcoracoid dislocations.. Moreover 
the patient supports the injured member with the opposite hand, which is uncommon in 
dislocations of the shoulder. On manipulating the arm distinct bony crepitus is elicited 
and an abnormal bony prominence is noted on the anterior aspect of the shoulder. 
The displaced head could be felt high in the axilla. An X-ray plate confirmed the 
diagnosis of fracture of the anatomical neck with suhcoracoid displacement of the head. 
Twenty-four hours later ecchymosis appeared covering the anterior portion of the shoul- 
der. Case was operated seven days following the injury. The displaced cap of bone 
was pulled back onto the upper end of shaft and wired in position. Outer and upper 
portion of greater tuberosity considerably comminuted. Bony union resulted and func- 
tion in articulation restored though extreme abduction remains slightly restricted. "Wire 
remains in place at the present time, five years later. 

Photograph taken about fifteen minutes" following the accident. Fracture produced 
by fall from bicycle, the blow being sustained on the outer aspect of the shoulder. 



DISLOCATIONS OF THE SHOULDER 



73 



cation later, or to obtain a false joint at the seat of the fracture. 
Both methods must, at the present time, be considered unsurgical 
and obsolete. McBurney was the first to deal with this condition 
in a satisfactory manner, treating the fracture and the dislocation 
at the same time by open incision. He devised a hook (see Fig. 95) 
by means of which he was able to manipulate the upper fragment 
so as to return the head to the glenoid, after which the fragments 
were adjusted, and wired or not as thought best. The end of the 




Fig. 98. 



Fig. 97. — X-ray of case shown in Fig. 96 taken before operation. Fracture of 
anatomical neck with displacement of the head into the axilla beneath the coracoid. 

Fig. 98. — Same case after operation. Head has been replaced and secured in 
position with a loop of wire. Perfect apposition not possible because of the crushing 
of cancellous tissue in the upper end of the bone. 



hook is inserted into a hole of proper size drilled into the upper 
fragment, the necessary leverage being thus secured. In fracture 
of the anatomical neck (which is even more unusual than fracture 
of the surgical neck) the McBurney hook is of little service in 
reducing a dislocation of the upper fragment. The cap of bone 
must be handled by means of tenacula because of its friable, can- 
cellous structure, and if reduction is impossible should be excised. 
Very serviceable joints frequently result after removal of the head. 



74 



FRACTURES AND DISLOCATIONS 




Fig. 99. — Same case after operation and recovery. Picture taken about eight weeks 
after operation. 




Figs. 100 and 101. — Stereoscopic view of a comminuted fracture of the anatomical 
nock of the humerus with subglenoid dislocation of the humeral head. The arrow points 
to the displaced head. 



DISLOCATIONS OF THE SHOULDER 



75 



When the head can be replaced it is often found necessary to secure 
it in position, which is most easily accomplished by wire (see Fig. 
98). A peculiar point to be noted here is that the head of the 
humerus almost never suffers necrosis, even though the upper frag- 







Fig 102.— Snhcovacoid dislocation conii.lHai.'d l.v fracture of the -i 
Fragment displaced. Arrows point to lines of fracture. 




iul>erositv. 



ment includes only the articular surface; and it is here that one 
might expect necrosis since the upper fragment is apparently 
cut off from its blood supply. 

Either of the tuberosities may he fractured in dislocations of the 



76 



FRACTURES AND DISLOCATIONS 



shoulder and may be displaced in the line of pull of the attached 
muscles. Reposition by open incision and fixation b}^ means of a 
loop of silver wire will be found most satisfactory. 

Two modes of approach are emploj^ed, one incision (the external) 
passes through the deltoid on the outer side of the shoulder, and 
the other (the anterior) is made in the sulcus between the deltoid 
and pectoralis major. In making the external incision the circum- 
flex nerve may be encountered in the lower part of the wound and 
should be avoided. In the low forms of the subcoracoid or the 
subglenoid dislocations some of the nerves of the brachial plexus 
or even the axillary artery ma}^ lie in front of the head, and in 
making the anterior incision the surgeon should be on the lookout 
for these structures. 

Injuries to the hrachial plexus call for operative intervention, 
but before this is attempted a careful neurological examination 
should be made to determine as accurately as possible the extent 




Fig. 103. 




Fig. 104. 

Figs. 103 and 104. — Two views of contracture of hand following dislocation of 
shoulder with injury to brachial plexus. 

of the damage and the region of the plexus injured. It should 
be remembered that the upper part of the plexus may be torn by 
the pull on the nerves when the humerus is displaced downward. 
Nothing in an operative way is indicated in instances in which one 



DISLOCATIONS OF THE SHOULDER 77 

or more of the nerves are bruised or stretched but when laceration 
occurs the ends should be approximated and sutured together. The 
patient should be fully appraised of the doubtfulness of the 
prognosis under such circumstances. 

Rupture of the axillary artery or vein with the development of 
an axillary hematoma (frequently of the pulsating type, when the 
artery is torn) calls for immediate operative intervention. The 
artery is temporarily^ compressed against the first rib to control 
hemorrhage and an incision made to expose the vessel in the region 
of the injury. Suture of the injured vessel is rarely possible. 
Ligation will be indicated. 

Old luxations of the shoulder may in some instances be reduced 
by manipulation, even after the head has been out of the glenoid 
for four or five months, though the longer the dislocation has existed 
the less the chance of reduction without open incision (see Fig. 
105). Great force should not be used in attempting to reduce 
these old dislocations because of the liability of injury to vessels 
or nerves or of producing fracture of the humerus. The fibrous 
tissue surrounding the head may involve the brachial plexus or 
axillarj^ artery, and when the head is forcibly returned to the 
glenoid these structures may be torn. When gentle manipulation 
does not produce the desired results open incision should be 
resorted to. The anterior incision is better adapted to freeing the 
head from the fibrous tissue surrounding it, while the external 
incision affords better access to the glenoid cavity for the removal 
of fibrous tissue which so frequently fills it. After the parts have 
been exposed, the head liberated and the glenoid cavity cleaned 
out there should be little difficulty experienced in returning the 
head to its normal position. Old rents in the capsule should be 
approximated by suture after the edges have been scarified. "When 
the incision enters the joint the divided capsule should be closed 
with catgut after reduction has been accomplished. Provision for 
the escape of blood which may subsequently ooze into the wound 
and joint should be made, so that there may be no dead spaces to 
favor infection. (See ''Open Treatment of Fractures," page 754.) 

Recurrent dislocations sometimes become so frequent that the 
usefulness of the arm is much impaired, and the only relief is 
through operative intervention, which consists in repairing the rent 
in the capsule and in plicating the same when necessary. 

Compound luxations of the shoulder are extremely rare. The 



78 



FRACTURES AND DISLOCATIONS 




Fio-s 105 106 and 107. — Three views of an old subcoracoid dislocation of left 
Ider of nearly five months' standing at the time the photographs were taken ihis 



dislocation" was" reduced at "the "first 'attempt by means "of Kocher's method with the 
patient in the standing position, which goes to show that cases of long standing are not 
necessarily operative cases. 



DISLOCATIONS OF THE SHOULDER 



79 



treatment of these conditions is essentially operative and should be 
carried out according to the principles laid down in the chapter on 
"Treatment of Compound Fractures and Luxations," page 789. 




Fig. 108. — This case is a strikiiij; example of refurvent dislocation of the shoulder. 
The photograph was taken immediately following reduction of the seventy-second dislo- 
cation of the patient's left shoulder. The use of the left arm is much impaired as the 
patient is continually guarding against the positions which he has learned from experi- 
ence are likely to produce displacement. The condition has extended over a period of 
many years and as a result of the disturbed function the muscles of the left shoulder 
show a very slight atrophy. 

After-Treatment. — In the uncomplicated cases of dislocation of 
the shoulder the arm should be immobilized for a period of three 
weeks, but under no consideration should we fail to employ passive 
motion as soon as the acute traumatic reaction has subsided. 
This will usually be at the end of five or six days. The arm should 
be fixed to the side and the forearm carried in a sling. A con- 
venient method is to sew the sleeve of the undershirt to the body of 
the garment. This prevents the arm from being carried far 
enough aw^ay from the body to strain the capsule. In performing 
passive motion the surgeon should avoid external rotation and 
extreme abduction since the former tends to open the rent in the 
capsule, Avhile the latter causes the injured portion of the capsule 



80 FRACTURES AND DISLOCATIONS 

to be stretched across the head of the bone. The duration of immo- 
bilization should be governed by the extent of the capsular lacera- 
tion. Prolonged immobilization without passive motion will result 
in more or less permanent loss of mobility, while on the other hand, 
unrestricted use of the member following reduction will almost 
surely be followed by a condition of recurrent dislocation. 

When fracture complicates dislocation the arm should be immo- 
bilized as in simple fracture of the humerus, from four to six weeks, 
until union takes place. Passive motion under these circumstances 
is not permissible prior to union, though careful massage may be 
begun as soon as the traumatic reaction has subsided. If it is 
found that the joint is much restricted in its motion after union is 
firm we may break up the joint adhesions by passive motion, using 
an anesthetic if necessary. This should not be attempted inside of 
two months following the injury, and only then when the X-ray 
shows a good callus at the seat of fracture. (See "Treatment of 
Fractures of the Upper End of the Humerus," page 97.) 

Prognosis. — In the simple uncomplicated dislocation (especially 
of the subcoracoid type) the restoration of function should be 
practically complete provided passive motion is instituted early 
and the patient is prevented from using the arm before the liga- 
ments have healed. The prognosis is rendered worse according to 
the presence and nature of complications. In injury to the axil- 
lary vessels collateral circulation is usually established if the mem- 
ber is properly cared for. Injury to the brachial plexus or some 
of its branches is not exceptionally rare and deserves a most guarded 
prognosis. It is true that injury to nerves has occurred during 
reduction, especially in cases in which the heel has been used as a 
fulcrum in the axilla, but on the other hand the surgeon not infre- 
quently has been blamed for paralyses which were produced at 
the time of the accident and for which he was in no way responsible. 
These unfortunate circumstances demonstrate the value of exam- 
ining the condition of the reflexes and of motion and sensation in 
the arm before any attempt at reduction is made. Pressure on the 
nerves by the head of the bone is usually accompanied by transitory 
symptoms and complete recovery. Laceration of the nerves is 
followed by permanent paralyses unless the nerve ends are united. 
Operation renders the prognosis better, though recovery is usually 
prolonged and often incomplete, especially if the condition is of 
long standing at the time of operation. In old unreduced luxations 



DISLOCATIONS OF THE SHOULDER 81 

the patient sometimes develops surprisingly good use of the arm 
as years go on. The betterment of the condition by operation is 
usually quite gratifjdng. Most recurrent luxations can be com- 
pletely cured by operation. Compound luxations are usually pro- 
duced only by great trauma and the prognosis will depend on the 
injury sustained by the surrounding soft tissues and the subsequent 
development of infection. The prognosis of these luxations is 
grave though modern operative treatment has improved the 
outlook greatly. 



CHAPTER YII. 

FRACTURES OF THE UPPER END OF THE HUMERUS. 

Surgical Anatomy. — The upper end of the humerus is deeply 
seated and extremely difficult of palpation unless dislocated. It 
will be noted that the normal lateral prominence of the shoulder 
is due to the head of the humerus beneath the deltoid muscle, and 
not to the acromion. The upper extremity of the bone is composed 
of cancellous tissue, as shown in Fig. 110, there being only a thin 
layer of compact bone on the surface. The manner in which the 
compact tissue of the shaft grows rapidly thinner as the end of the 
bone is approached is well shown in the section of bone just referred 
to in Fig. 110. The internal structure is deserving of careful study 
since it explains some of the deformities and the variations in the 
types of fracture occurring at different levels. In addition the 
surgeon should appreciate the internal structure as well as the 
surface form in performing operations for the direct fixation of 
fragments. The attachment of the capsule corresponds to the 
anatomical neck except on the inner aspect of the bone where it is 
attached a little below the line of the neck. The muscles attached 
to the upper end of the bone are important in explaining the de- 
formities occurring in the presence of fracture. The muscles 
inserted into the greater tuberosity are, from before backward, the 
supraspinatus, infraspinatus and teres minor. These three muscles 
arise from the supraspinous fossa, infraspinous fossa and axillary 
border of the scapula respectively, and pass in almost straight lines 
to their insertions into the greater tuberosity. These muscles when 
unopposed by the weight of the limb and the muscles inserted into 
the shaft, tend to produce outward rotation and abduction of the 
upper fragment. The subscapularis arises from the subscapular 
fossa and passes directly to its insertion into the lesser tuberosity. 
When unopposed it tends to produce inward rotation. It lies to the 
inner side of the joint and is in contact with the capsule. When 
the shaft is separated from the upper end of the bone the muscles 
attached in the region of the bicipital groove tend to produce 

82 



FRACTURES OF UPPER END OF HUMERUS 83 

inward displacement of the upper end of the lower fragment. 
These muscles are the pectoralis major, teres major and latissimus 
dorsi. 

Fractures of the upper end of the humerus may show great varia- 
tion, yet in most instances the injury will conform more or less 
accurately to one or more of the following types : fracture of the 




Fis. 109. Fig. 110. 

Fig. 109. — Upper end of humerus in young subject. Note position of epiphyseal 
line. E.. epiphysis; E.L., epiphyseal line; D., diaphysis. 

Fig. 110. — Coronal section of same bone. M., metaphysis. Note the manner in 
which the diaphysis projects into the epiphysis and the relative distribution of can- 
cellous tissue. 

anatomical neck, fracture of the tuberosities, fracture of the surgi- 
cal neck and separation of the epiphysis. 

Fracture of the anatomical neck occurs in middle and old age and 
is usually the result of direct violence. The line of fracture seldom 
corresponds exactly with the anatomical neck. The most usual 
variations of fracture of the anatomical neck are : fracture of the 



84 



FRACTURES AND DISLOCATIONS 



anatomical neck through its inner half or two-thirds (the outer 
portion of the fracture being so placed as to include the greater 
tuberosity with the upper fragment),— splitting of the upper end 
of the bone with fracture of the anatomical neck and impaction of 




Fig. 111. — Rontgenogram of shoulder of child nine years of age. Note the relations 
of the epiphyseal cartilage and compare with Figs. 109 and 110. 



the head into and between the tuberosities, — fracture of the 
anatomic neck in its outer half with a portion of the inner side of 
the shaft attached to the upper fragment. The line of fracture 
very rarely follows the anatomical neck throughout, but when it 



FRACTURES OF UPPER END OF HUMERUS 



85 



does the upper fragment is left free from muscular and ligamentous 
attachments and is as likely to be displaced in one direction as 
another. Fracture of the anatomical neck is usually accompanied 
by more or less crushing of the internal cancellous tissue in the 




Fig. 112. — Fracture of anatomical neck of humerus. Fracture in this region 
seldom follows the anatomical neck throughout but includes the upper portion of the 
greater tuberosity with the head, as in this case. 



upper end of the bone and impaction of the fragments is not un- 
common. 

Fractures of the tuberosities as isolated injuries are extremely 
rare. They are most commonly associated with dislocations of the 
shoulder and may occur with fracture of either the anatomical or 



86 



FRACTURES AND DISLOCATIONS 



surgical neck. Avulsion of a scale of bone from the greater tuber- 
osity corresponding to the insertions of one or more of the attached 
muscles has been reported in a few cases and is the result of muscu- 
lar action Undoubtedly this condition has existed m many cases 
and been mistaken for a "sprain." Isolated fracture of the lesser 






Fig. 113. — Fr; 



uf surgica'l neck of humerus. Good position of fragments 



tuberosity is even more rare than fracture of the greater tuberosity. 
It is known to have been avulsed by overaction of the subscapularis. 
Fracture of the lesser tuberosity is most often seen as a complica- 
tion of dislocations of the shoulder, especially those of the posterior 
variety. The fragment is displaced by the pull of the attached 



FRACTURES OF UPPER END OP HUMERUS 87 

muscle and usually lies in the axilla internal to and below the 
head. 

Fractures of the surgical neck are much more common injuries. 
The surgical neck is that portion of the bone between the epiphy- 
seal cartilage and the insertions of the pectoralis and teres major. 
When fracture occurs in this region the lowTr fragment will be 
displaced. inward by the pull of the pectoralis major, latissimus 
dorsi and teres major and overriding will be effected by the action 




Fig. 114. — Fracture of surgical neck with considerable comminution along line of 
fracture. 

of the biceps, triceps, deltoid and coraco-brachialis. The upper 
fragment will be controlled by the muscles attached to the tuberosi- 
ties and is usually displaced forward and may be abducted or 
adducted. The lower fragment may be driven upward into the 
upper fragment, or the serrated surfaces sufficiently engaged to 
partially or completely oppose the displacing action of these 
muscles. 

Pronounced inward displacement of the upper end of the lower 
fragment may produce injury to vessels and nerves. The lesions 



88 FRACTURES AND DISLOCATIONS 

will be similar to those already mentioned as occasionally compli- 
cating dislocations of the shoulder. 

Epiphyseal separation of the upper end of the humerus is not 
an uncommon accident. The upper epiphysis of the humerus is 
ossified from two centers, one for the head and one for the greater 
tuberosity. Occasionally an additional center is seen for the lesser 
tuberosity. The ossific center for the head is present at birth, that 
for the greater tuberosity is first seen during the third year. "When 
the lesser tuberosity is ossified by a separate center it is usually 
not seen until the fifth year. The head and greater tuberosity 
are fused at the sixth year so that the epiphysis is. one piece of bone. 



W^' 



Fig. 115. — Fracture of surgical neck with deformity. Comminution of upper fragment. 

The epiphysis joins the shaft at about the twentieth year. Sep- 
aration of the epiphysis may occur at any time prior to the twentieth 
year, but is most commonly seen from the ninth to the seventeenth 
years. The position of the epiphyseal cartilage is well shown in 
Figs. 110 and 111. It will be noted that the cartilage is roughly 
horizontal but that the center is much higher than the margins. 
This is probably due to the fact that the epiphysis is ossified from 
two centers. The conical conformation of the end of the diaphysis 
accounts for the fact that recurrence of deformity is seldom seen 
following reduction of an epiphyseal separation in this region. 
The joint cavity may be opened, but more often is not. When the 
diaphysis is displaced the deformity is similar to that seen in 



FRACTURES OF UPPER END OF HUMERUS 89 

fractures of the surgical neck; that is, the upper end of the shaft 
is pulled imvard by the action of the pectoralis major, teres major 
and latissimus dorsi and raised by the muscles of the arm. 

Etiology. — Fractures of the upper end of the humerus are the 
result of direct and indirect violence. Fracture af the surgical 
neck is the most common break in this region. Fracture of the 
anatomical neck occurs mostly in the aged. Epiphyseal separations 
are seen only in children and adolescents. Various types of frac- 
ture of the upper end of the humerus are occasionally seen as com- 
plications of luxations of the shoulder. 




Fig. 116. — Ti-;iiisvt'r,s(- frarturi' of tlu' surgical neck with iJronounced deformity 



Symptoms. — The symptoms accompanying fracture of the upper 
end of the humerus will vary according to the nature and severity 
of the lesion. If the fragments are free the symptoms will usually 
be pronounced. When impaction exists the symptoms may be so 
slight at first that the patient continues to use the part, although 
there is always more or less pain and discomfort. Swelling about 
the shoulder is almost constant and an abnormal prominence 
anteriorly (see Figs. 119 and 124) usually accompanies fractures 
in this region. Function is completely lost in unimpacted cases 
but is often only partially so when the fragments are impacted. 
Pain is constant though the degree is quite variable. It is always 
more severe in unimpacted cases. Ecchymosis usually develops 
within twelve to twenty-four hours following the fracture. The 



90 



FRACTURES AND DISLOCATIONS 



attitude of the patient is usually characteristic. The upper part 
of the trunk is inclined forward and toward the injured side, and 
the injured arm is supported with the opposite hand. This attitude 




Fig. 117. 



Fio-. 118. 



Figs. 117 and 118. — Two views of recent fracture of the surgical neck of the 
humerus. Note the abnormal prominence on the anterior aspect of the shoulder, also 
change in axis of humerus which is not accompanied by flattening of the shoulder as 
seen in dislocations. Very slight shortening of the arm present. Note how patient 
grasps the injured member with opposite hand (an attitude seldom seen in dislocations of 
the shoulder). Picture taken about half an hour following the accident. 




Fig. 119. — Same case seen in the recumbent position. Note that the abnormal 
prominence on the anterior aspect of the shoulder is not changed by the patient's lying 
down. 



is usually not assumed in isolated fracture of one of the tuberosities 

but only when there is solution of continuity in the humeral shaft. 

In fracture of the anatomical neck impaction is not uncommon 

and accordingly the symptoms may not be severe. Pain is present 



FRACTURES OF UPPER END OF HUMERUS 91 

on moving the shoulder. Swelling is constant. Abnormal mobility 
will be present unless the fracture is impacted but the proximity of 
the shoulder joint to the point of false motion often renders the 
condition difficult of recognition. Deformity may be present but 
is much less common than is the case in fracture of the surgical 
neck. Slight flattening of the shoulder may be noted but is uncom- 
mon. The humeral neck is usually thickened. Alteration in the 
humeral axis may be apparent in the uncommon cases in which 
there is lateral displacement of the fragments. 

In fraciure of the greaiev tuberosity the power of outward rota- 
tion will be diminished and motion of the shoulder, especially rota- 




Fig. 120. — X-ray of case shoAvn in Figs. 117, 118 and 119. Fracture of surgical 
neck of humerus. 

tion, will be attended by pain. Swelling is variable. Local tender- 
ness is constant. By applying a stethoscope to the shoulder and 
rotating the humerus it may be possible to detect crepitus which 
would otherwise escape recognition. The normal joint sounds and 
those occurring in arthritis should not be confused with true 
crepitus. It may in some cases be possible to palpate the displaced 
fragment. In fracture of the lesser tuherosity the power of internal 
rotation will be lost or lessened and it may be possible to palpate 
the displaced fragment in the axilla, below and to the inner side of 
the humeral neck. 



92 



FRACTURES AND DISLOCATIONS 



In fracture of the surgical neck the symptoms are more pro- 
nounced and constant. Impaction is rare, pronounced deformity is 
the rule. The upper end of the lower fragment is usually displaced 
upward, forward and inward, or upward and inward. The more 
pronounced the lateral displacement the more apparent will be the 
change in the axis of the humeral shaft. Pain is usually severe and 
the suffering greatly increased by motion of the shoulder. Injuries 
to nerves and vessels are unusual though they are more common in 
this fracture than in any other occurring in the upper end of the 
humerus, and the accompanying symptoms are similar to those 




Fig. 121. 



Fig. 12-. 



Figs. 121 and 122. — Fracture of surgical neck of humerus twelve hours after 
injury. Note the undue prominence of the shoulder anteriorly which is greater than 
would be present in simple swelling of the shoulder following sprain. Note also the 
ecchymosis which almost never follows dislocation. Note the attitude of the patient in 
grasping the injured member with the opposite hand. In dislocations the patient seldom 
makes any attempt to support the injured member but in fractures of this region it is 
often difficult to get him to let go of it even for an instant. Injury sustained in this 
case by blow on the upper and outer aspect of the arm. Patient about 60 years of age. 



described under "Dislocations of the Shoulder," page 76. Pain, 
mobility, crepitus, loss of function, swelling, ecchymosis and 
deformity are more pronounced and characteristic in fracture of 
the surgical neck than they are in any other fracture occurring in 
the upper end of the humerus. The accompanjdng illustrations will 
give the reader a good idea of the usual clinical picture accompany- 
ing fractures of the surgical neck. 

In epiphyseal separations of the upper end of the humerus the 
symptoms are similar to those seen in fractures of the surgical neck. 
Displacement, however, is not as constant, loss of function is 
variable, and crepitus soft and cartilaginous. Separation of the 



FRACTURES OF UPPER END OF HUMERUS 



93 




Fig. 123. — Rontgenogram of case shown in Figs. 121 and 122. 




Fig. 124. — Low fracture of sargical neck of right humerus. Note the shortening 
of the arm on injured side. The lower end of the upper fragment is displaced forward, 
producing the abnormal prominence indicated by arrow, while the lower fragment is 
displaced upward. Note the tight grasp on the fingers of the injured member. This 
attitude was assumed even after the patient was requested to release his hold on the 
forearm higher up. (See Diagnosis.) Only slight change in humeral axis. Photograph 
taken about three hours following injury. (Note evidence of syphilis in WOse sud com- 
pare with Figs. 462 to 465,) 



94 



FRACTURES AND DISLOCATIONS 




Fig. 125. — 'Same ca^c (Fi.:. IJi' m<,i \ inulicnt ])Msifi()ii Xotr tli.M tlic change 

in position does not intlueiice the pro.muence on llu' antei'ior asiiect nt tlic shoulder. 
It is easy to see that the prominence indicated by arrow is produced by for^'ard 
displacement of the upper fragment since the axis of the arm and therefore of the lower 
fragment is only slightly altered. Compare Avith Fig. 127, in which both fragments are 
angulated. 




126 



Fig. 127. 



Figs. 126 and 127. — Yonth, age 15 years. Fell about fifteen feet and struck on 
left shoulder. Pain and disability present on rising from ground. Promptly attended 
by physician who diagnosed dislocation and treated same by Kocher's method. Case 
seen by another physician a few days later. First seen by author about three weeks 
following injury when photographs were taken. Note prominence on anterior aspect 
of shoulder and shortening of arm, both signs indicative of fracture. Pen outline on 
arm indicates the positions of the fragments as revealed by palpation. Arm can be 
caii-ied only a short distance forward because of the defornaitv interfering. Diagnosis 
confirmed by X-ray. (See Fig. 128.) 



FRACTURES OF UPPER END OF HUMERUS 95 

upper epiphysis may occur without displacement and the loss of 
function may be only partial. Under these conditions the surgeon 
may fail to recognize the nature of the injury. When deformity 
is present the upper end of the diaphysis is usually displaced for- 
ward and inward and on examination of the shoulder the lesion 
is noted at a higher level than that seen in fracture of the surgical 
neck. The anterior aspect of the shoulder is characteristic. The 
prominence caused by the upper end of the diaphysis can, as a rule, 
be appreciated by inspection alone. 

An epiphyseal separation without deformity may easily escape 
recognition immediately following the injury. If the shoulder is 




Fig. 128. — X-ray of case shown in Figs. 126 and 127. 

not immobilized subsequent strain is likely to produce displacement 
and the characteristic deformity, together with the accentuation of 
the symptoms, discloses the nature of the injury. 

Diagnosis. — The diagnosis of fractures of the upper end of the 
humerus is based on the symptoms just enumerated and when 
these are typical there should be little difficulty in determining the 
nature of the injury. A thorough and systematic examination of 
the shoulder should be made in every case and the possibility of 
associated fractures of the clavicle and of dislocations of the 
shoulder and acromio-clavicular joint should be kept in mind. 

With the patient seated in a straight chair the arms are placed 



96 FRACTURES AND DISLOCATIONS 

in symmetrical positions and the parts carefully inspected before 
any manipulation is attempted. jMuch can be learned by inspection 
alone and if this source of information is fully utilized much un- 
necessary manipulation can, as a rule, be avoided. In fractures of 
the clavicle the shoulder is usually lowered but the arm itself is 
not shortened. The over-riding deformity so common in fractures 
of the clavicle is usually apparent. In dislocations of the shoulder 
the change in humeral axis, flattening of the shoulder and lowering 
of the axillary fold should indicate the nature of the injury at a 
o-lance. The attitude in dislocations is characteristic in that the 




Fig. 129. — Measuring humeral length — from acromion to external epicondyle. 

Fig. 130. — Palpating humeral head through deltoid. 

Fig. 131. — Palpating humeral head with finger tips pressed into axilla. 

patient seldom makes any attempt to support the injured member 
with the opposite hand. In fractures of the upper end of the 
humerus the injured arm is grasped and supported with the greatest 
anxiety. Both active and passive motion are restricted in disloca- 
tions while abnormal mobility is the rule in fractures. Ecchymosis 
is common about the shoulder within twelve to twenty-four hours 
following a fracture, but in luxations it is almost never seen except 
in the rare subspinous type. Flattening of the shoulder is some- 
times seen in fractures of the anatomical neck but it is never as 
pronounced as in dislocations and is not accompanied by change in 
the humeral axis. 

The head of the humerus should be palpated through the deltoid 
and again through the axilla. If the arm is carried through rota- 
tion while the head is palpated the surgeon may determine to his 
satisfaction whether or not the head follows the movements of the 
shaft. The shaft of the humerus should be measured from the edge 



FRACTURES OF UPPER END OF HUMERUS 97 

of the acromion to the external epicondyle and compared with the 
opposite side. Shortening usually means fracture, while length- 
ening is indicative of the more common types of dislocation (sub- 
coracoid and subglenoid) . The coracoid process should be palpated 
where it approaches the surface about an inch below the junction 
of the middle and outer thirds of the clavicle. The clavicle, 
acromion and spine of the scapula should be palpated. The arm 
should be carried through the normal range of motion and restric- 
tion in any given direction and increase of pain should be noted. 

Fracture of the neck of the scapula may be difficult to distinguish 
from fracture of the upper end of the humerus. If fracture of the 
upper end of the humerus can be excluded and still there is ab- 
normal mobility of the upper end of the bone with crepitus, the 
symptoms are indicative of fracture of the glenoid or neck of the 
scapula. It may be possible in some cases to palpate the margin 
of the displaced glenoid in the axilla. 

Diff^erentiation of fractures of the upper end of the humerus from 
luxations of the shoulder and fractures and dislocations of the 
clavicle is usually not difficult, but to distinguish between the differ- 
ent types of fracture occurring in the upper end of this bone is 
often not an easy matter without the aid of the X-ray. The 
symptoms of fracture of the anatomical neck, surgical neck, 
tuberosities and epiphyseal separations have been enumerated and 
will serve in making a differential diagnosis in typical cases pending 
the making of a Kontgenogram. 

The possibility of increasing the damage to the soft parts should 
be borne in mind and manipulation should be as gentle and brief 
as possible. Motion, sensation and the deep reflexes of the upper 
extremity should be tested to recognize complicating injuries to the 
nerves and vessels. The condition of the circumflex may be ascer- 
tained by tapping the deltoid and noting the contraction of its 
fibres. 

If manipulation is especially painful or the swelling pronounced, 
the examination is best conducted under anesthesia. 

Treatment. — Reduction of the fragments should in most cases be 
done under anesthesia. A careful consideration of the physical 
signs and symptoms will, as a rule, afford the surgeon sufficient 
information concerning the fracture to correct the deformity. 
The parts should then be immobilized and an X-ray taken to deter- 
mine the position of the fragments and the details of the fracture. 



98 



FRACTURES AND DISLOCATIONS 



The upper end of the shaft may be displaced in any direction and 
accordingly the manipulations of reduction will vary in different 
cases. The usual deformity, however, consists in an upward and 
inward displacement of the upper end of the lower fragment. Re- 
duction will therefore usually consist in forcing the upper end of 
the shaft outward, while traction is being exerted on the arm. In 
making outward pressure on the upper end of the shaft the surgeon 
should avoid exerting the pressure directly over the end of the frag- 
ment, otherwise vessels and nerves may be forced against the sharp 
serrated end and injured. The effect of manipulation can, as a 
rule, be recognized by palpation through the axilla. With the frag- 




Fig. 132. — Shows cigar-box boards cut te proper size to make a diagonal axilUir 
pad. The ends to the right have been hinged together -with adhesive plaster. 

ments in good positicn there should be a disappearance of deformity. 
In impacted cases, however, and in those accompanied by consid- 
erable crushing of cancellous tissue, a certain amount of shortening 
may persist, which is impossible to correct. The deformit}^ in frac- 
tures of the upper end of the humerus varies greatly, but if the 
surgeon appreciates the relative positions of the fragments and the 
nature of the break he will usually be able to effect a satisfactory 
reduction by means of extension, counter-extension and manipula- 
tion. The reduction of epiphyseal separations involves the same 
principles. 

With reduction accomplished the question of fixation arises. 
The methods of immobilization are similar for most types of frac- 



FRACTURES OF UPPER END OF HUMERUS 99 

ture of the upper end of the humerus. The most common method 
of immobilization, and one which will be adapted to the largest 
number of cases, is accomplished by means of the axillary pad and 
the moulded plaster shoulder cap. Various methods of preparing 




Fig. 133. — Shows axillary pad completed. Cotton has been packed in betweeii the 
boards and a layer of cotton used to cover the surface. The whole is then bandaged. 

and applying these two elements in the dressing have been described 
and there is little to be said of any of them as long as they accom- 
plish the desired result, which is fixation of the fragments in proper 
position without undue constriction of the arm or irritation of the 





Fig. 134. Fig. 165. Fig. 136. 



Fig. 134. — View of axillary pad from behind. Note how the pad supports the 
humerus down to the internal epicondyle. 
Fig. 135. — Same seen from the front. 
Fig. 136. — Same with arm raised. Note the oblique lower end of pad. 

skin. The details of the most satisfactory methods will be described. 
The key-note to the proper immobilization of the shoulder is the 
axillary pad. 

The axillary pad should support as much of the humerus as pos- 



100 FRACTURES AND DISLOCATIONS 

sible without interfering with the upper part of the forearm which 
is maintained in a position of semiflexion. A very satisfactory pad 
is made in the following manner: take two pieces of cigar-box (the 
lid and bottom) and cut them so that they will be a little broader 
than the arm and then hinge two of the ends together inside and 
out with adhesive as shown in Fig. 132. The boards are then placed 
in the opposite axilla (hinged ends up) for the purpose of measuring 
and marking the proper length. The pad when completed should 
come to about the level of the internal epicondyle posteriorly, but 
should be short enough anteriorly to clear the top of the semi- 
flexed forearm. To accomplish this it will be found necessary to 
cut the lower ends of the boards diagonally (as shown in Fig. 132). 
With the boards cut to the proper size (due allowance being made 
for the padding) the angle is stuffed with cotton till a wedge of the 
proper thickness is obtained. The outside of the pad is then cov- 
ered with cotton and finished by securing the padding in position 
with a roller bandage. The tendency for those not accustomed to 
constructing this dressing is to make the pad too long, and when 
this is done the antero-inferior angle will make the patient miserable 
by pressing into the upper part of the forearm, or else the pad will 
tend to slip backward and fail to properly support the humerus. 
The outer side of the pad should be evenly covered so that it will 
present a flat plane for the humerus to rest on. The pad is secured 
in position by three pieces of adhesive as shown in Figs. 135 and 
136. Two of them pass over the opposite shoulder while the third 
encircles the body. The surgeon should see to it that the pad is 
properly fitted and placed before he proceeds with the making of 
the shoulder cap. Heavy card board (book-binders board) may be 
used in place of the wood, but if the material is too light the 
sides will tend to bow when the angle is stuffed with cotton, as 
described above. When this occurs the side of the pad does not 
present the necessary flat surface for the humerus to rest against. 
Light card board is entirely inadequate, and stuffing of the space 
between the body and trunk, with folded towels is mentioned simply 
to be condemned. Many different methods of making an axillary 
pad may be followed but the above will be found as satisfactory 
as any. 

The plaster shoulder cap is shown in Fig. 137 and is applied as 
follows: After reduction has been effected and the axillary pad 
placed in position, a pattern is cut out of sheet-cotton to properly 



FRACTURES OF UPPER END OF HUMERUS 



101 



embrace the arm and shoulder. It is best to lay the cotton on the 
shoulder and cut the pattern in this position. Ten or twelve layers 
of crinolin (or half again as many layers of gauze) are then cut 




Fig. 137. — Plaster shoulder cap in position. Note the encircling strap of adhesive 
plaster. 

according to the pattern, immersed in plaster cream, wrung out and 
applied to the shoulder. The sheet-cotton pattern is applied to the 
shoulder first and acts as the lining for the shoulder cap. The 




Fig. 138. 



Fig. 139. 



Fig. 140. 



Fig. 138. — Axillary pad in position and arm bandaged. 

Fig. 139. — Plaster shoulder cap in position. 

Fig. 140. — Swathe encircling body and taking place of sling. 

shoulder cap should be secured to the body as quickly as possible 
with a wide roller bandage and the patient kept perfectly quiet 
until the plaster has thoroughly set and dried. Later on the 



102 



FRACTURES AND DISLOCATIONS 



bandages may be removed and the cap secured in position by means 
of a body swathe or strips of adhesive plaster. Another method of 
securing the arm and splint to the body is by encircling both with a 
sufficient number of turns of plaster bandage. Wet crinolin 
bandage may be used instead. When this is done the trunk should 



^^A 





> ' B ^^ 



Fig. 141. 



Fi?. 142. 




Fig. 143. 

Fig. 141. — Middeldorf triangle. 

Fig. 142. — The Monks triangle. A. shows the wire bent to proper form. B. shows 
same padded and bandaged. 

Fig. 143. — Osgood-Penhallow splint for treatment of fractures of the upper end of 
the humerus in abduction. 



be protected with sheet cotton to prevent subsequent irritation of 
the skin. The cap should cover the shoulder on all sides, and if 
additional security is desired it may be made to extend well onto 
the chest both in front and behind. In fractures of the upper end 
of the humerus it will seldom be necessary to include the elbow or 
forearm in the splint. 



FRACTURES OF UPPER END OF HUMERUS 103 

It is well to snugly bandage the arm, forearm and hand with a 
flannel bandage before the pad and shoulder cap are applied. 

A method offering very solid fixation is a plaster spica of the 
arm and chest though it does not permit of frequent removal or easy 
adjustment during the after-treatment. When the spica is em- 
ployed the arm and chest should be well covered with sheet cotton, 
and after the dressing is finished an axillary pad should be placed 
in position to support the arm. 

The cravat sling is called for with any of the plaster dressings 
about the shoulder except when the forearm is included in the 
splint. 

It is advisable in most cases of fracture of the upper end of the 
humerus to employ an anesthetic during examination and reduc- 
tion though it is more satisfactory to apply a plaster dressing when 
the patient is conscious and able to assume a convenient position. 
When the causative trauma is great and the ensuing traumatic 
reaction pronounced it is often better to treat the patient in bed 
during the first few days and to delay the application of a perma- 
nent dressing. During this time the arm may be secured on an 
axillary pad and sand bags applied to the outer side of the arm to 
steady the parts. The local and intermittent use of the ice cap 
will be of service in controlling the inflammatory reaction. In some 
instances the patient will be more comfortable with the arm resting 
on a pillow. If the suffering is great, morphine should be ex- 
hibited. 

Occasionally cases are seen in which reduction cannot be main- 
tained with the arm in a position such as assumed when the 
axillary pad and plaster shoulder cap are employed. Abduction, 
outward rotation or a forward displacement of the upper fragment 
may require a corresponding position of the lower fragment to keep 
the fractured surfaces in apposition and the fragments in align- 
ment. To meet the requirements in such cases a number of splints 
have been devised. The Middledorf triangle maintains the arm 
in a position of partial abduction and inward rotation and is effec- 
tive in some cases in preventing recurrence of deformity. (See 
Fig. 141.) The Monks triangle holds the arm in a nearly horizontal 
position with the elbow carried forward. (See Fig. 142.) 

By means of a plaster cast of the upper extremity and trunk 
the arm may be fixed in almost any position desired. Taking every- 
thing into consideration it is probably the most satisfactory form 



104 



FRACTURES AND DISLOCATIONS 



of immobilization in instances in which the arm may not be treated 
at the side because of displacement of the upper fragment. 

When uncomfortable and awkward positions, such as maintained 
by the above splints, are necessary to keep the fragments in proper 
relation, the question of operation should be considered. It is the 
author's opinion that most cases of this kind (in Avhich reduction 
cannot be maintained with the arm by the side) should be operated 
upon, and the fragments secured in position by direct fixation. 




Fig. 144 



Fig. 144. — Plaster cast for treatment of fracture of the upper end of the humerus 
in abduction. In applying the cast the humerus may be fixed in almost any position 
desired. 

Fig. 145. 
in abduction, 
tion. 



-Plaster cast for treatment of fractures of the upper end of the humerus 
This cast fixes the humerus in a position of greater outward rota- 



Operative Treatment. — The cases of fracture of the upper end 
of the humerus in which operation is indicated are numerous but 
the proper selection of these cases requires the most seasoned surgi- 
cal judgment. Fractures in which the displacement is pronounced 
and not reducible by ordinary methods should be operated. Recur- 
rence of deformity during the after-treatment is ordinarily an indi- 
cation for operative intervention. Cases in which the upper frag- 
ment is abducted, rotated, or displaced forward may be treated 
by some form of dressing which immobilizes the arm in a position 
corresponding to the deformity of the upper fragment. Such dress- 
ings, however, are more or less uncomfortable and insecure and in 
most instances it will be advisable to expose the fragments, wire or 
plate them together and then fix the arm hy the side with the 
ordinary axillary pad and shoulder cap dressing. 



FRACTURES OF UPPER END OF HUMERUS 105 

The fragments are to be exposed througli a vertical incision on 
the anterior or external aspect of the shoulder. The circumflex 
nerve will be found winding around the surgical neck of the bone 
and should be avoided. It is best to expose the fragments by dull 
dissection in the deeper part of the wound until the nerve has been 
located and isolated. With the fragments exposed the needs of the 
case are determined and the details of the operation from this time 
on will vary accordingly. Reduction of deformity is performed by 
means of extension, counter-extension and manipulation, and is 
rendered easier by direct manipulation of the fragments when 
necessary. The fact that the fragments may be directly inspected 
during manipulation is of the greatest service in correcting the 
displacement. If a firm engagement between the fragments can be 
obtained by manipulation th^ wound may be closed and the opera- 
tion concluded; if, however, there is a tendency to redisplacement 
some form of internal fixation must be employed. A consideration 
of the illustration on page 83 will show that the structure of the 
bone above the surgical neck is composed of a wide-meshed cancel- 
lous tissue covered only by a very thin layer of compact bone, and it 
is in this formation that very little dependence can be placed on 
nails, pegs, screws, etc. Silver wire will afford the most trust- 
worthy fixation and should be given the preference in the region of 
the anatomical neck. It is frequently the case that a simple loop 
of wire passing through the outer side of the fracture as shown in 
Fig. 98 will secure a safe and accurate apposition. The Lane 
plate has been used in the region of the greater tuberosity though 
it is not reasonable to expect security from it when the screws 
holding it are not placed in a fairly heavy layer of compact tissue. 
Accordingly it is of greater value a little lower in the bone. It is 
sometimes necessary to excise the head of the bone because of 
extensive comminution, or in old cases because of non-union. It is 
well to remember that the head very rarely suffers necrosis follow- 
ing separation from the shaft. Attempts to save the head are 
usually successful with accurate apposition and the proper degree 
of fixation. Reduction and fixation of fractures of the surgical 
neck are not as a rule attended by great difficulty unless there is 
extensive comminution of the upper fragment. When the upper 
fragment is broken into many pieces it may be impossible to com- 
pletely restore the bone to its original lines. A wire encircling the 
surgical neck, with notches in the bone to prevent its slipping down- 



106 FRACTURES AND DISLOCATIONS 

ward, may be of great value in lorLgitudinal splitting. It should 
be so placed as not to interfere with the long head of the biceps. 
Isolated fractures of the tuberosities are rare injuries. Little 
difficulty should be experienced in returning the detached tuberosity 
to its original position and securing it in place. 

In epiphyseal separations reduction of the deformity will usually 
be all that is required, as displacement is prevented by the projec- 
tion of the center of the diaphysis upward into the epiphysis. 
(See Figs. 110 and 111.) Suture of the periosteum on the outer 
side of the bone will increase the security of reduction. If a tend- 
ency to recurrence of deformity is present absorbable suture 
material may be passed through drill holes in the bone. Non- 
absorbable suture material should not be used across an epiphj^seal 
cartilage. 

It is well to insert a small drain of silkworm gut before the wound 
is closed to relieve the joint of blood and serum ; this drain should 
be removed in from twenty-four to forty-eight hours. 

After-Treatment. — In the average child or young adult union 
may be expected at the end of four weeks, while a middle-aged 
person should be allowed from five to six weeks for callous forma- 
tion. In the aged union may be much delayed. The acute swelling 
about the joint will usually have subsided at the end of ten days or 
two weeks. During the time the shoulder is decreasing in size the 
padding on the inside of the shoulder cap will require frequent 
changing and adjustment so that the cap may properly fit the 
shoulder. If the swelling has been great it may be necessary to 
apply a new cap when the shoulder approaches the normal in size. 

The case should be seen daily for the first ten days, after which 
every two or three days will be sufficient. The axillary pad some- 
times becomes loosened and is likely to slip downward or back- 
ward, and if not replaced may be responsible for a change in the 
position of the fragments. Gentle passive motion should be begun 
at the end of two or two and a half weeks in uncomplicated cases. 
Passive motion should at- all times be gentle, and the production 
of pain must represent the limit of motion. The splints should 
be removed at the end of four to six weeks, according to the age 
and condition of the patient, and the arm carried in a sling for 
another ten days. The patient should be especially cautioned not 
to submit the arm to any great strain for the first two months fol- 
lowing the removal of splints. Extreme abduction is the last mo- 



FRACTURES OF UPPER END OF HUMERUS 107 

tion to be regained by the patient and in elderly persons it is not 
infrequently lost permanently. Should paralysis of any of the 
nerves supervene during the after-treatment (as evidenced by 
wrist drop or contractures) we should lose no time in exploring the 
nerve involved where it crosses the line of fracture. The circum- 
flex is the single nerve most frequently involved in fractures of the 
upper end of the humerus. End results following operations on 
the nerves cannot be expected inside of four to six months at the 
earliest. Atrophy of the deltoid not infrequently occurs from 
disuse alone without injury to the circumflex. This condition is 
not in itself a cause for anxiety since the muscle will regain its size 
and tone with use. 

Following reduction of an epiphyseal separation fixation should 
be maintained for three or four weeks. 

Early passive motion is of the greatest value in fractures of the 
upper end of the humerus. Restricted motion in the shoulder is 
often the result of a too prolonged immobilization. If joint ad- 
hesions are present after union is firm they may be forcibly broken 
up under anesthesia, but before this is attempted the surgeon should 
be positive that the callus is firm enough to stand the manipulation 
without re fracture. 

Prognosis. — The outlook in fractures of the upper end of the 
humerus will depend on the severity of the break and the age and 
condition of the patient. A fair degree of reduction will usually 
be followed by perfect recovery in youthful subjects. The older the 
patient the greater the probability of incomplete restoration of 
function. In the aged non-union may follow in spite of the most 
perfect treatment. In patients past middle life there is often 
slight restriction of motion and pain about the joint occurring with 
changes in the weather. The range of motion may be free and yet 
the shoulder weak. 

Loss of growth following epiphyseal separation is an extremely 
rare condition and need not be expected if anything like a fair 
reduction has been accomplished following the accident. IModerate 
deformity, if present, will decrease as the years go by. 



CHAPTER YIII. 

FRACTURES OF THE SHAFT OF THE HUMERUS. 

Surgical Anatomy. — To appreciate the deformities accompan^'ing 
fractures of the shaft of the humerus the attachments and directions 
of pull of the different muscles should be known. - (See Figs. 146 
and 147.) AMien the line of fracture is through the insertions of 
the pectoralis major, latissimus dorsi and teres major the deformity 
is usually slight and consists of an in\Yard displacement of both 
fragments so that the deformit}^ is, as a rule, purely angular. 
When the fracture is below the insertions of these muscles, but aboA'e 
the deltoid eminence, the lower fragment will usuall}^ be displaced 
upward and outward by the deltoid, while the upper fragment is 
drawn inward by the pull of the pectoralis, teres, and latissimus. 
When the fracture is below the insertion of the deltoid the upper 
fragment will be displaced outward. In any fracture of the 
humeral shaft the serrated ends may be firmly enough engaged to 
prevent lateral and overriding displacement, and under such cir- 
cumstances the deformity is purely angular if present at all. 
Shortening of the arm is caused for the most part by the action of 
the biceps and triceps. 

The humerus has a wider range of motion than any other bone 
in the body and the varieties of strain to which it ma}' be subjected 
are great. Accordingly we may see any type of fracture common 
to long bones. The shaft of the humerus is composed of a heavy 
tube of compact tissue which grows larger in circumference and 
lighter in structure as the extremities are approached. 

The musculo-spiral nerve supplying the extensors and supinators 
descends obliquely, from a^bove, downward and outward, between 
the two humeral heads of the triceps. It lies in contact with the 
bone in the musculo-spiral groove and in this position is particu- 
larly exposed to injury in fractures of the humeral shaft. It may 
be injured by direct contusion and laceration at the time of the 
accident or it may be subsequently caught and compressed by the 
callus. 

lOS 



FRACTURES OF SHAFT OF HUMERUS 



109 




Figs. 146 and 147. — Views of the anterior and posterior surfaces of the right 
humerus. The arrows indicate the pull of the attached muscles. 

H., Head of the humerus; A.N., Anatomical neck; S.N., Surgical neck; L.D., At- 
tachment of the latissimus dorsi ; T.M., Attachment of the teres major; Cb., Coraco- 
brachialis; T'., Outer head of the triceps; T"., Inner head of the triceps; M.S., Musculo- 
spiral groove; B., Bicipital groove; P.M., Insertion of the pectoralis major; I.. Infra- 
spinatus; T.Min., Teres minor; D., Insertion of the deltoid; S.L., Supinator longus ; 
E.G.R.L., Extensor carpi radialis longior; JJ., Groove for ulnar nerve; P.R., Pronator 
radii teres; F.F., Flexors of the forearm; F.G.U., Flexor carpi ulnaris; Tro., Trochlear 
surface of humerus; C, Capitellum; E.F., Extensors of the forearm. 



110 



FRACTURES AND DISLOCATIONS 



Inward displacement of one or both of the fragments may be the 
cause of laceration or compression of the brachial artery which lies 
to the inner side of the shaft. 

Green-stick fractures are seldom seen and multiple breaks are 
uncommon. Direct violence is usually responsible for fractures of 
the transverse type; spiral and oblique fractures are the result of 
twistinpr strains. Muscular action is especially productive of frac- 




Fig. 148. 



Fig. 148. — Spiral, comminuted fracture of humeral shaft. 

Fig. 149. — Fracture of shaft with overriding and rotary deformity. 



ture of the humeral shaft, and in some cases (particularly in elderly 
persons) the degree of causative trauma may be disproportionately 
small. Impaction of the fragments is almost never seen. 

The most common seat of fracture is at or a little below the 
middle of the shaft. 

Symptoms. — There is pain, loss of function, crepitus, abnormal 
mobility and varying deformity. Swelling usually develops rapidly 
and ecchymosis is seen within the first day. The relative position 
of the fraorments varies with the level of the break and has been 



FRACTURES OF SHAFT OF HUMERUS 



111 



explained under ''Surgical Anatomy," page 108. The deformity 
is almost always sufficiently pronounced to be recognized by inspec- 
tion alone. 

The patient supports the injured member with the opposite 
hand in a manner which is characteristic. (See Diagnosis under 
"Dislocations of the Shoulder," page 65.) 

The patient is able to move the hand and fingers, and the reflexes 
below the site of the fracture are intact unless some of the nerves 
have been injured. 




Fig. 150. — Multiple spiral fracture of humeral shaft with pronounced deformity. 
Fig. 151. — Oblique fracture of humeral shaft with separation of fragments. (Taken 
through heavy fibre splint.) 



A weakening or absence of the radial pulse indicates laceration 
or compression of the brachial artery.^ 

The development of a hematoma may sometimes be recognized 
in the arm following tearing of the artery. 

Diagnosis. — Fractures of the humeral shaft are, as a rule, 
recognized without difficulty. The deformity is usually so pro- 
nounced that the diagnosis can be made by inspection alone. As 
soon as the arm is manipulated the point of abnormal mobility 
is apparent in almost all cases. Fracture of the shaft is a common 
fracture and is not infrequently associated with injuries to neigh- 



1 A thrombosis of the brachial artery may 
alteration in the pulse will be delayed. 



be slow in forming and when it is the 



112 



FRACTURES AND DISLOCATIONS 



boring bones or joints. The surgeon should therefore be system- 
atic in his examination and determine the conditions of the clavicle, 




Fig. 152. — Oblique fracture of humerus a little below its middle Avith overriding and 
angular displacement of the fragments. Upper fragment anterior and external to lower 
fragment. Line of fracture passes below in-^ertion of deltoid, hence the outward dis- 
placement of upper fragment, while the biceps and triceps cause the fragments to over- 
ride. In this t^pe of fracture complete reduction is often impossible without operative 
intervention. Photograph taken within an hour of the accident. 




Fig. 153. — Crushing injui-y of ;u-m. This case was struck by a falling wall, the 
humerus fractured and the upper purtiou of arm forced through rent in skin. Skin 
and fascia only tissues connecting upper and lower portions of arm. Arrow points to 
lower end of upper fragment directly above which m.ay be seen tip of hemostat holding 
end of brachial artery. Amputation. Recover^-. Photograph taken while patient is 
under anesthetic and just prior to operation. 

scapula, elbow, ribs, etc., before the diagnosis can be considered 
complete. An X-ray plate should be made to afford further 
information concerning the nature of the fracture. 



FRACTURES OF SHAFT OF HUMERUS 113 

Treatment. — The treatment will vary according to the location 
of the fracture and the direction and degree of displacement. It 
is best in most instances to reduce the deformity under anesthesia. 
Traction, counter-traction and manipulation will suffice in 
many cases to bring the fragments into proper apposition and 
alignment. In transverse fractures with overriding (especially 
when the ends are deeply serrated), reduction can best be effected 
by producing angular deformity and manipulating the fragments 
in this position until the serrated ends have been engaged. The 
bone is then straightened and appropriate dressings applied. In 
producing angular deformity for the purpose of engaging the ends, 
the arm should be bowed outward, to avoid stretching of the artery 
and nerves which lie on the inner side of the shaft. It is usually 
not difficult to effect reduction of a spiral or oblique fracture but it 
is frequently impossible to prevent recurrence of deformity in 
breaks of these types without resorting to internal fixation. Out- 
ward rotation of the upper fragment in a spiral or oblique fracture 
may act as a serious obstacle to reduction. 

Fractures of the upper third of the shaft are to be treated with 
dressings such as already described in the Treatment of ''Fractures 
of the Upper End of the Humerus" (page 101), namely axillary 
pad, plaster shoulder cap, cravat sling, body swathe, etc. There 
is this to be said, however, in regard to the shoulder cap ; the lower 
the fracture the greater the need of extending this dressing down- 
ward to include the forearm. Coaptation splints are often used in 
fractures of the middle of the shaft though they may well be dis- 
pensed with, as a permanent dressing, in favor of a properly applied 
shoulder cap. It is a common practice to treat the condition during 
the onset and subsidence of swelling with the axillary pad, coapta- 
tion splints, body swathe and sling. Later on the coaptation splints 
are replaced by the plaster shoulder cap as a permanent dressing. 
In fractures of the lower third the elbow should be solidly immobil- 
ized. The axillary pad is not appropriate, and carrying the arm 
in a sling is entirely inadequate to secure fixation if the fracture is 
near the elbow. A most satisfactory method of fixation in this 
portion of the shaft is that shown in Fig. 215 and is described below. 

The following may be considered a fair example of the treatment 
of a fracture of the shaft of the humerus shortly following the acci- 
dent. The patient is placed in as comfortable a position as possible, 
preferably the recumbent, and an examination made of the parts, 



114 



FRACTURES AND DISLOCATIONS 



to determine as accurately as may be the exact nature and position 
of the fracture. The examination is more satisfactorily carried out 
under anesthesia. It should be remembered that the less the parts 
are manipulated the better it will be for the soft tissues surrounding 
the jagged ends of the fragments. After the fracture has been 
diagnosed the proper dressings should be prepared so that every- 
thing may be in readiness as soon as reduction has been effected. 




Fig. 154. — Stromeyer cushion. 



It is needless to add that the surgeon should, at this time, satisfy 
himself as to which form of dressing \Yill best meet the requirements 
of the case in hand. In instances in which the trauma has been 
great it is often best to leave the parts undisturbed and to treat 
the patient in the recumbent position for a week or ten days until 
the acute inflammatorv reaction has subsided. Durino- this time 




Fig. 155 



Fig. 155. — Arm bandaged and axillary pad in position. 

Fig. 156. — Coaptation splints applied. 

Fig. 157. — Swathe encircling body and acting as sling, 
elusive.) 



Fig. 15' 



(See Figs. 132 to 14^ 



the arm may be supported- on a pillow and the ice cap used to 
control the reaction. The Stromeyer cushion, or one of its modifi- 
cations, may be used to advantage. If, on the other hand, it seems 
advisable to immobilize the arm at once the following details may 
be observed. The arm and side of the chest are sponged, dried and 
dusted with talcum powder, special attention being paid to the 
axilla. An axillar}^ pad is then constructed as described on page 



FRACTURES OF SHAFT OF HUMERUS 115 

100. Coaptation splints are next made by placing thin wood on 
adhesive plaster (cigar-box wood is excellent) and splitting the 
wood with a knife. The splint should include as much of the arm, 
from the shoulder to the elbow, as possible without pressing into the 
axillary fold above, or the top of the flexed forearm below. The 
portion of the coaptation splint on the outer side of the arm may 
be longer than that on the inner side. A body swathe is next pre- 
pared of two or three thicknesses of heavy muslin. It should be 
long enough to encircle the body and injured member and broad 
enough to extend from the top of the shoulder to a point below tlie 
elbow. A cravat sling is then prepared and the necessary materials 
are ready. 

The axillary pad is placed in position and secured with adhesive 
plaster, after which the surgeon is ready to attempt reduction. 
The injured member is grasped above and below the seat of frac- 
ture, and the fragments gently but firmly manipulated until the 
senses of sight and touch pronounce the position satisfactory. The 
coaptation splint is then well padded, applied and secured in 
position with adhesive plaster. The arm is then firmly placed 
against the axillary pad and secured by the body swathe. The 
cravat sling completes the dressing, or in lieu of the sling the fore- 
arm may be included in the swathe, allowing the hand to emerge 
between the layers where they are pinned together. This form of 
dressing is least likely to strangulate the arm during the first week 
of treatment when the traumatic reaction and swelling are in 
progress. 

A very satisfactory method of fixation in fractures below the 
middle of the shaft is one in which internal and external plaster 
splints are used, as shown in Fig. 215. These splints are made of 
plain gauze (from fifteen to twenty ply) and should be reinforced 
at the elbow^ by the insertion of additional layers of gauze between 
the layers of the splint. The external splint extends from a point 
well up on the shoulder, along the back of the arm and forearm to 
the wrist, while the internal splint extends from just below the 
axillary fold to the wrist on the anterior aspect of the upper 
extremity. They are applied to the injured member while wet and 
rapidly secured in position with a roller bandage. The surgeon 
holds the fragments in proper reduction until the plaster has set. 
Specific instructions should be given to the patient and his attend- 
ants not to allow the splints to be covered with clothing or bed 



116 FRACTURES AND DISLOCATIONS 

covers for at least twenty-four hours so the plaster may become 
thoroughly dried out. One or two folded towels should be placed 
between the arm and the body, and a light swathe used encircling 
the chest and injured member. The following day the splints 
should be removed one at a time, lined with a layer of sheet cotton 
and replaced. The splints should then be secured in position by 
means of strips of adhesive plaster encircling the arm. The body 
swathe may be used in securing the arm by the side, or strips of 
adhesive may be used for this purpose. Sufficient padding should 
be placed in the external splint in the region of the olecranon to 
avoid chafing and discomfort. This dressing is quite secure but 
requires careful watching to avoid strangulation w^hen swelling 
sets in. It is of particular advantage in compound fractures of 
the lower end of the humeral shaft since the arm may be perma- 
nently secured to one splint while the other is removed daily for 
inspection and dressing of the wound. 

After the arm is immobilized (whatever the type of dressing 
may be) an X-ray should be taken, when possible, to verify the 
diagnosis and to determine the accuracy of reduction. 

When overriding deformity cannot be corrected by solid engage- 
ment of the fractured ends weights may be attached to the elbow 
to control the action of the biceps and triceps. (Fig. 214.) 

The use of extension may be indicated in some cases if employed 
in the recumbent position, but as an ambulatory method it is, in 
the author's opinion, entirely too haphazard and untrustworthy to 
be relied upon, notwithstanding statements to the contrary. It may 
be stated as a rule that fractures of the shaft requiring permanent 
extension to maintain reduction should be submitted to operation, 
and the fragments wired or plated in position. If ambulatory 
extension is employed, and fails, w^e have a condition of deform- 
ity W'hich we know only too well might have been prevented by 
proper operative intervention. 

Operative Treatment. — Fractures of the humeral shaft are fre- 
quently of the oblique or spiral type and accurate reduction is 
often impossible without open incision and internal fixation. The 
frequency w^tli which one sees deformity following fractures of 
the humeral shaft treated by non-operative methods, indicates the 
value of open incision in the treatment of breaks in this region. 

It is usually best to approach the bone through an external longi- 
tudinal incision of sufficient length to allow free access for manipu- 



FRACTURES OF SHAFT OF HUMERUS 



117 



lation and reduction. The greatest care should be used to avoid 
injury to the musculo-spiral nerve in making the incision and in 
accomplishing reduction and fixation. Destruction of the function 
of this nerve will be more disastrous to the patient than non-union 
of the fragments or union with deformity. It should be kept in 
mind therefore that it is possible for the surgeon to produce an 




Fig. 158. 



Fig. 158. — Rontgenogi'am of spiral fracture of humerus after two attempts at re- 
duction. Rotary and lateral deformity present. 

Fig. 159. — Same case after operation, showing fragments held in reduction by two 
wires. The lower wire encircles the bone while the other, at a higher level, penetrates 
the shaft and secures leverage for the lower wire. 

injury which is far worse than the condition which he is operating 
to correct ; accordingly the course of the musculo-spiral nerve should 
be thoroughly appreciated before operation in this region is 
attempted. 

After the fragments have been exposed the nature of the fracture 
is accurately ascertained, reduction accomplished and the best 
method of fixation determined. Each case must be considered by 
itself, and the nature of the deformity fully appreciated before 



118 



FRACTURES AND DISLOCATIONS 



Fig. 160. — X-ray of same bone after it had been 
removed from soft tissues. Note the density and dis- 
position of the callus nine months after operation 
and compare this plate with the photographs of the 
bone shown in Figs. 161, 162 and 163. 

Figs. 161, 162 and 163. — Same case as shown 
in Figs. 158, 159 and 160. Patient had suffered 
from chronic chorea for past twenty-five years and 
sustained fracture as a result of the staggering gait 
which caused the fall. Fixation was particularly diffi- 
cult on account of the nature of the fracture and the 
choreoid spasms and wiring was resorted to. Nine 
months later patient died in the terminal dementia 
following Huntingdon's chorea and humerus was ob- 
tained at autopsy. By comparing this specimen with 
Figs. 158, 159 and 160 the disposition of the callus 
( overing the wire will be readily appreciated. The 
wire A. encircling the shaft has been covered by 
crllus where it crosses the line of fracture. The wire 
B. was passed through a drill hole in both fragments 
and did not encircle the shaft; this wire also is cov- 
ered by callus where it crosses the line of fracture. 
Restoration of function was complete some months 
prior to death. The dotted outline shows where the 
nnihculo-spiral nerve crosses the bone in the fresh 
specimen; wire A. was originally passed between the 
nerve and the bone. 



160. 




Fig. 162. 




A 
Fig. 163. 



FRACTURES OF SHAFT OF HUMERUS 119 

internal fixation is employed. Lateral displacement and over- 
riding deformit}^ in spiral fractures can usually be prevented by 
a wire encircling the shaft and including both fragments. (See 
Figs. 158 and 159.) A second wire is then placed a short distance 
from the first to secure the proper leverage in preventing angular 
deformity. In passing the circular wire about the shaft some form 
of hook (such as shown in Fig. 826) should be used to avoid includ- 
ing the musculo-spiral nerve. The Lane plate has been used in 
this region with most satisfying results and has much to commend 
it (see page 766). 

After-Treatment. — The after-care of fractures of the humeral 
shaft is as important as reduction. The bone is deeply seated and 
difficult to immobilize and the dressings require daily inspection 
and adjustment during the first ten days. Undue constriction of 
the parts must be avoided and still the dressings must be tight 
enough to properly support and immobilize the arm. In other 
words, the arm is changing in size because of the swelling, and the 
dressings must be made to vary accordingly, so they may fulfill 
their proper function. When fixation is satisfactory union should 
be present at the end of four weeks in children, and in from five 
to six wrecks in adults. The older the patient the slower the bone 
will be in uniting. After the removal of splints the arm should be 
carried in a sling for another two or three weeks. Massage, early 
passive motion and hot applications will hasten the restoration of 
function. The arm should not be subjected to excessive strain for 
three to four months following the injury. 

Prognosis. — In children and healthy young adults the restora- 
tion of function should be rapid and complete, if proper reduction 
and immobilization have been carried out, and union is usually firm 
at the end of four weeks. In adults five to six weeks is necessary. 
Non-union is more common here than in any other bone in the body, 
and is usually due to incomplete reduction or lack of proper im- 
mobilization. Laceration of the musculo-spiral nerve at the time 
of injury will be followed by paralysis and contractures, if not 
exposed and repaired. Even when the ends are united recovery is 
tedious and often incomplete. The development of paralysis of 
this nerve during the after-treatment may be due to compression 
by the callus and unless relieved by operation gives a bad prognosis. 



CHAPTER IX. 

FRACTURES OF THE LOWER END OF THE HUMERUS. 

Surgical Anatomy. — The lower end of the humerus articulates 
with two bones; the types of these articulations are entirely different 
and the fractures occurring in this region are complex. The lower 




Fig. 164 (top). Fig. 165. Fig. 166 



Fig. 164. — Anterior surface of lower end of right humerus. I.E., internal epicon- 
dyle; C, capitellum ; T., trochlea. 

Fig. 165. — Lower end of left Jiumerus seen from below. T., troclilea ; C, capitel- 
lum; I.E., internal epicondyle ; E.E., external epicondyle. 

Fig. 166. — Mesial aspect of lower end of left humerus. I.E., internal epicondyle: 
E.T., edge of trochlea. 

end of the bone curves forward and is flattened from before back- 
ward. The articular surfaces may be described roughly as a 
cylinder mounted on the lower end of the shaft, with the axis of the 
cylinder nearly transverse to the long axis of the shaft. The outer 

120 



FRACTURES OF LOWER END OF HUMERUS 121 

end of the cylinder is at a slightly higher level than the inner end. 
When the elbow is fully extended the arm and forearm are not in 
the same straight line but form an angle of about 170 degrees. 
The difference between this angle and a straight line is 10 degrees, 
half of which is caused by the obliquity of the articular surfaces of 
the Icwer end of the humerus, wliile tlie other half is tlie result of 
the position of the bones of the forearm. In complete extension, 
therefore, we have the ''carrying angle" wliile in complete flexion 
the forearm comes in contact with and folds directly upon the arm. 
AYhen the fragments, in fractures of the lower end of the humerus. 




Fig. 167. Fig. 168. 

Fig. 167. — "Crescentic" fracture of lower end of humerus. Slight lateral displace- 
ment. 

Fig. 168. — "Crescentic" fracture of lower end of liumerus with more pronounced 
lateral displacement. 

are allowed to unite in deformity there may be a disturbance in 
the carrying angle which is apparent when the arm is extended, 
and in addition there may also be a deformity in which the fore- 
arm does not fold directly against the arm in acute flexion. The 
carrying angle varies considerably in different individuals and the 
examination should therefore include comparison with the unin- 
jured elbow. 

A certain amount of hyperextension is normal in the elbow, and 
by means of this position longitudinal stress may be borne by the 
upper extremity independently of the extensor muscles, tlie action 
resembling that seen in the knee when the joint is hyperextended. 



122 FRACTURES AND DISLOCATIONS 

The lower end of the humerus is deserving of detailed considera- 
tion so that the fractures occurring in this portion of the bone may 
be more thoroughl}- understood. 

The external condyle (epicondyle) is a small, tubercular eminence 
situated just above and a little external to the capitellum. It 
affords attachment to the external lateral ligament and some of 
the extensor and supinator muscles of the forearm. It is rarely 
fractured without at least a portion of tlie capitellum being included 
with the fragment. 

The capitellum is the rounded eminence occupying the outer 
part of the articular surface. It articulates with the head of the 




Fig. 



Fig. 169. — A^ertical fracture of lower end of humerus separating external condyle 
from remainder of bone. 

Fig. 170. — Fracture of the external condyle with lateral displacement of elbow. 
Fracture of the olecranon present but not discernible from this angle. 

radius, and is rarely injured except when involved in some of the 
more common fractures of the external condyle. The radius artic- 
ulates below with the carpus and above with the capitellum, and in 
falls on the hand violence is transmitted directly to the capitellum 
through the radius. This type of violence, however, is much more 
likely to produce Colle's fracture or a break in the sliaft, neck or 
head of the radius. The obliquity of the fibres of the interosseous 
ligament enables the ulna to absorb a portion of the shock when 
violence is sustained in this way. The capitellum occupies only the 
front and lower part of the bone. 

The inner portion of the articular surface is taken up by the 



FRACTURES OF LOWER END OF HUMERUS 



123 



trochlea wliicli articulates with the greater sigmoid cavity of tlie 
ulna. It presents a pronounced groove running from before back- 
ward which is bounded on either side by prominent ridges, the 
inner being the most marked and extending to a lower level. The 




Fig. 172. 

Fig. 171. — T-fracture of lower end of humerus. Pronounced inward and backward 
displacement of lower fragments. 

Fig. 172. — "Crescentic" fracture of lower end of humerus with lateral and back- 
ward displacement of lower fragment. 




Fig. 173. — Supracondylar fracture with pronounced inward and back-ward displace- 
ment of lower fragment. 

Fig. 174. — 'Same case after reduction. 

trochlea is slightly spiral so that the posterior end is a little external 
to the anterior extremity. Just above the anterior end of the 
trochlea is situated the coronoid fossa which, during flexion of the 
elbow, receives the process on the ulna of the same name. On the 



124 



FRACTURES AND DISLOCATIONS 



posterior aspect of the bone in the same corresponding position is 
found the olecranon fossa. These two fossae are ordinarily sep- 
arated by only a thin layer of bone and when the depressions are 




Fig:. 175. — "Crescen-lic" fracture with backward and rotary displacement. 

Fis. 176. — Fracture of lower end of humerus with backward and rotary displace- 




Fig. 177. 



Fig. 178. 



Fig. 177. — Fracture of lower end of humerus. Deformity not apparent in antero- 
posterior view. 

Fig. 178. — Same case seen laterally. Slight backward displacement of lower frag- 
ment. 

well marked the bone may be perforated, forming the supracondylar 
foramen. These two fossge materially weaken the construction of 
the lower end of the humerus and are usually entered by transverse 



FRACTURES OF LOWER END OF HUMERUS 125 

fractures in this region, and by vertical fractures involving the 
articular surfaces. 

The internal condyle (epitrochlea) is much more prominent and 
larger than the external condyle, and affords attachment to the 
internal lateral ligament and some of the pronators and flexors of 
the forearm. It is more easily broken than the external condyle. 
Directly behind this process is a groove for the ulnar nerve which 
is not infrequently injured in fractures of the internal condyle. 

The manner in which the lower epiphysis of the humerus is 
ossified is of importance in explaining epiphyseal separations in 
this region, though the resultant conditions are treated in a manner 
similar to fractures of the same parts. At birth the epiphysis is 
entirely cartilaginous and throws no shadow under the X-ray, 
while the lower end of the diaph^^sis is rounded. (See Fig. 251.) 





Fig. 17 



Fig. 179. — Epiphyseal separation of epitrochlea. 
Fig. 180. — Lateral view of same case. 

Before the end of the first year the center for the capitellum 
makes its appearance. At the sixth year the center for the internal 
condyle is seen; during the eleventh year the trochlea begins to 
ossify and the center for the external condyle is first seen during 
the twelfth year. The outer three centers usually fuse with each 
other and join the diaphysis during the fifteenth year, before the 
center for the epitrochlea becomes continuous with either epiphysis 
or diaphysis. The internal condyle joins the rest of the bone at 
about the eighteenth year. During the latter part of the develop- 
ment of the lower end of the humerus the diaphysis is seen to 
project progressively further into the epiphysis so that it comes 
nearly to the surface between the centers for the internal epicondyle 
and trochlea. The order in which these centers join the shaft and 
the thinning of the epiphysis between the trochlea and internal 



126 



FRACTURES AND DISLOCATIONS 



epicondyle account for the relative frequency of epiphyseal sep- 
arations of the internal epicondjde. 

The ligaments about the elbow play an important part in pro- 
duction of fractures. With the elbow partially flexed, abduction 
or adduction of the forearm produces rotation of the humerus. 
With the elbow fully extended, however, there is practically no 
rotary effect on the humerus but instead extreme tension is pro- 
duced on one of the lateral ligaments. If the forearm is abducted 
the head of the radius is forced against the capitellum and the 
internal lateral ligament is placed under tension. If the violence 




Fig. 181. — Fracture of internal epicondyle. 

Fig. 182. — Separation of epiphysis of external condyle. 

Fig. 183. — Separation of epiphysis of internal epicondyle. 



is sufficient the capitellum is fractured, or the bone supporting it is 
broken off from the remainder of the lower end of the humerus. 
Instead of either of these lesions the internal lateral ligament may 
suffer rupture, or an equivalent fracture of the internal epicondyle 
or trochlea may take place. When the elbow is extended and the 
forearm forcibly adducted the reverse mechanism obtains. 

If the forearm is forcibly extended beyond the normal limita- 
tions of motion the usual result is either rupture of the ligaments 
or fracture of the lower end of tlie humerus, with backward dis- 
placement of the fragment. A much more exceptional fracture is 
one produced by extreme flexion. 

The types of fracture occurring in the lower end of the humerus 
are numerous, and have for the most part been named according 



FRACTURES OF LOWER END OF HUMERUS 127 

to tlie portion of the bone involved. The terminology employed 
by different authors varies and the result has been rather confusing. 
The usual fractures occurring in this region are : 

Fracture of the epicondyle. 

Fracture of the external condyle including the capitellum. 

Fracture of the internal condyle including tlie trochlea. 

Fracture of the epitrochlea. 

Dia-condylar fracture, the break passing transversely through 
the condyles. 

Supra-condylar fracture, the break passing just above the con- 
dyles. 

T- or Y-fracture, in which a vertical break divides the lower 
fragment of a supra- or dia-condylar fracture. 

Comminuted fracture of the lower end of the humerus, in which 
the lower end of the bone is so broken up that it is difficult 
to recognize any particular type of fracture. 

Fracture limited to the capitellum as a result of violence trans- 
mitted through the radius in falls on the hand. 

Epiphyseal separations as described above. 

It wdll be noted that all of the above fractures, except the last 
two named, may be described as either ''transverse" or "vertical" 
or a combination of these two. The supra-condylar and dia- 
condylar fractures are essentially transverse, while the fractures 
involving the condyles and traversing the articular surfaces are 
vertical. The Y- or T-fracture shows both vertical and transverse 
elements. Nearly all transverse fractures pass through the ole- 
cranon fossa as do the vertical fractures involving the. articular 
surfaces. 

Transverse fractures are usually the result of forced hyper- 
extension of the elbow, and the lower fragment is almost invariably 
displaced backward. In the typical transverse fracture the low^er 
fragment is crescentic, the concavity looking upward. This type 
of fracture has frequently been mistaken for an epiphyseal sep- 
aration in spite of the fact that there should be no difficulty in 
differentiating the two conditions when the X-ray is employed. 

The upper end of vertical fractures may cross either the internal 
or external supracondylar ridge, but the lower end of the break is 
frequently placed so that the trochlea is separated from the capitel- 
lum. This separatioii of the two articular surfaces on the lower 



128 FRACTURES AND DISLOCATIONS 

end of the humerus allows a flail-like lateral mobility at the elbow 
which is characteristic of the injury. A rare displacement, some- 
times seen in transverse fractures, is one first described by Posadas, 
in which the lower fragment is displaced forward while tlie bones 
of the forearm are luxated backward. 

AVhen the condyles are separated from each other by a vertical 
fracture, one or both of the condyles may be displaced so that the 
relation of the three bony prominences is disturbed. 

In the normal elbow the prominence of the olecranon and the two 
condyles should be about on the same straight line when the elbow 
is fully extended. The olecranon is a trifle neai-er the inner con- 
dyle. When the elbow is in a position of acute fl(^xion these three 
bony prominences should occupy the apices of an equilateral tri- 
angle. This anatomical relation is of great value both in diagnosis 
and treatment. The muscles attached to the condyles may exert a 
displacing action when either of these processes is detached. In 
vertical fractures the condyles are usually further apart than they 
should be, and the condyle on the detached fragment may be dis- 
placed forward, backward, upward or downward. In any fracture 
in which the lateral stability of the elbow is destroyed the carrying 
angle is lost as the arm hangs by the side, and if the condition is 
severe the forearm may diverge to the inner side, producing the 
familiar "gunstock deformity," or cubitus varus. This deformity 
may occur with any of the transverse fractures and with the vertical 
fractures involving the articular surfaces. Immediately following 
the accident this deformity is due to gravity and to the position 
occupied by the displaced fragment or fragments. If the frag- 
ments are not replaced and recurrence of displacement prevented 
the deformity will become permanent when union takes place. 

In the rare T-fracture or in extensive comminution of the lower 
end of the humerus the lateral stability of the joint is most com- 
pletely broken up since both condyles are separated from the shaft 
and from each other, and the line of fracture divides the articular 
surface. This type of fractiire usually results from a fall directly 
on the flexed or semiflexed elbow. 

Symptoms. — The symptoms accompanying fractures of the lower 
end of the humerus vary considerably according to the position of 
the fracture and the severity of the lesion. Pain. sAvelling, local 
tenderness, loss of function and deformity are all present though 
they vary somewhat with the nature of the fracture. The traumatic 



FRACTURES OF LOWER END OF HUMERUS 



129 



reaction following fractures of the lower end of the humerus is 
usualh^ pronounced, and a few days following the accident the 
region of the elbow" may be covered with blebs containing blood 
or serum. Ecchymosis usually develops within twelve to twenty- 
four hours and may be extensive. The loss of function is usually 
complete following transverse fractures or those which involve the 
articular surfaces. In isolated fracture of either the epicondyle or 
epitrochlea the loss of function may be surprisingly slight. The 
patient will be able to use the elbow to some extent though of course 
the action of the part is somewhat limited by pain. 

The symptoms peculiar to the different fractures in this region 
v;ill be considered in detail. 




Fig. 184. — Fracture of external epicondyle with upward displacement of fragment. 
Prominence on external aspect of elbow suggestive; palpation reveals fragment. Joint 
is intact, there being no involvement of articular surface. Condition rare. 



Fractures of the epicondyle (fractures in which the joint is not 
entered and the capitellum remains intact) are extremely rare and 
the symptoms are not pronounced. Moderate local swelling and 
tenderness in the region of the external condyle is present. The 
fragment may remain in position or may be displaced in any direc- 
tion. When deformity exists the fragment is usuallj^ displaced 
downward. The detached particle of bone can, as a rule, be directly 



130 



FRACTURES AND DISLOCATIONS 



palpated and, if the fractured surfaces can be rubbed together, 
crepitus will be noted. Crepitus may be difficult to elicit if the 
fragment is not displaced and the swelling is pronounced. De- 
tachment of the epicondyle will destro}^ to a greater or less extent, 
the function of the external lateral ligament and accordingl}^ the 




. 186. 



Figs. 185 and 186. — Two views of a fracture of lower end of humerus without the 
characteristic baclvward clisphicement of Uiwer fragment. Note prominence of external 
epicondyle which is detached. The .ioint remains intact and hence the absence of de- 
formity such as seen in Figs. 188 and 189. 




Fig. 187. — Splitting of lower end of humerus with separation of external condyle. 
Gun-stock deformity and abnormal lateral mobility. Picture taken a few hours follow- 
ing accident. 



lateral stability of the elbow may be somewhat disturbed. A vary- 
ing degree of abnormal adduction of the elbow is often possible. 

Fractures of the external condyle (vertical fractures which enter 
the joint and include the capitellum in the detached fragment) are 
much more common than fractures of the epicondyle and the 



FRACTURES OF LOWER END OP HUMERUS 131 

symptoms are decidedly more pronounced. Pain is severe, loss of 
function complete and swelling pronounced. The lateral stability 
of the elbow is usuall}' completely lost and the joint is flail-like 
in a transverse direction. Crepitus is, as a rule, recognized as soon 
as the parts are manipulated. On palpating the condyles the epi- 
condyle is found detached from the humerus, while the epitrochlea 
is continuous with the rest of the bone. The forearm is usually 
supported by the uninjured member and the patient is reluctant to 
release it for examination. When the arm hangs by the side the 
helplessness of the member is apparent and the usual "gunstock" 
deformity is recognized at a glance. The fragment is usually dis- 
placed downward and may be so rotated that the fractured surfaces 
are no longer parallel and facing each other (see Fig. 218). 

Fractures of the internal condyle (vertical fractures entering the 
joint and separating all, or a portion, of the trochlea from the 
remainder of the bone) . The symptoms are similar to those alread}^ 
described in the preceding type except that the inner side of the 
elbow is the most painful and tender, and the internal condyle is 
found to be the movable part. Loss of lateral stability is even 
more pronounced than in fracture of the external condyle. 

Fracture of the epitrocMea (a vertical fracture separating the 
internal epicondyle from the remainder of the bone without entering 
the joint or involving the trochlea) is not an uncommon injury, 
and since neither the joint cavity nor the articular surfaces are 
involved the symptoms are usually slight. There is some local 
tenderness and pain on the inner side of the elbow, and ecchymosis 
is usually seen within the first day. Flexion and extension of the 
elbow^ are not painful except in as much as they disturb the detached 
fragment. Extreme extension or acute flexion may be attended by 
pain. Local swelling is usually present. The symptoms are often 
so slight that the condition is not infrequently mistaken for a 
sprain and treated as such. 

Supracondylar and diacondylar fractures are similar conditions 
and the symptoms so resemble each other that they wdll be de- 
scribed together. Swelling, pain, tenderness, loss of function, 
crepitus, and mobility are present as in vertical fractures involving 
the articular surfaces. Loss of carrying angle and even gunstock 
deformity are usually prominent symptoms. The deformity is 
often characteristic, the bones of the forearm and humeral frag- 
ment being displaced backward in such a w^ay as to produce a strong 



132 



FRACTURES AND DISLOCATIONS 




Fig. 138. — Transverse fracture of the lower end of the humerus. Note the back- 
ward displacement of the elhow. Palpation reveals the three bony prominences all dis- 
placed backAvarcl without disturbance in their relative positions. Sigmoid cavity of ulna 
not empty, as in Fig. 229. Picture taken about twenty-four hours following accident. 
Note sv\'elling and slight ecchvmosis. 




Fig. 189. — Same case in sitting position. Note that the defonnitv persists with 
change of position. The elbow is flail-like yet the action of the biceps and triceps pro- 
duce and maintain the deformitv. 



FRACTURES OF LOWER END OF HUMERUS 



133 




Fio-. 190 



Figs. 190 and 191. — X-ray plates of case shown in Figs. 188 and 189 after incom- 
plete rednctiou. 





:\i 




Fig-. 193. 

Figs. 192 and 19o. — L'oiupound comminuted fracture of lower end of humerus. 
Note the backward and inward displacement which is characteristic, Forearm is cov- 
ered with blood which accounts for its darkened condition in the photograph. Arrow 
points to the wound just above and behind the elbow. Picture taken about one hour 
after injury. 



134 



FRACTURES AND DISLOCATIONS 



resemblance to backward dislocations of the elbow (see page 159). 
The character of the deformity is well shown in Figs. 188 and 189. 
On palpation the two condyles are found to be no longer continuous 
with the shaft of the humerus though they are continuous with each 
other and move together. If the upper end of the ulna is palpated 




Fig. 194. 




Figs. 194 and 195. — Compound comminuted fracture of the lower end of the 
humerus. Note the deformity and flail-like condition. 



the greater sigmoid cavity will be found occupied by the lower end 
of the humerus and not empty as in backward luxation. The lateral 
stability of the elbow is destroyed. The characteristic deformity of 
a supra- or dia-condylar fracture is first the backward displacement 
of the elbow and second the '^gunstock" deformity. (See Figs. 
192 and 193.) 

In iJie T- or Y -fracture of the loiver end of the humerus or in 



FRACTURES OF LOWER END OF HUMERUS 



135 



cases in which the lower end of the hone is extensively comminuted 
practically all the symptoms of the above described transverse and 
vertical fractures are present in exaggerated form. The lateral 




Figs. 196 and 197. — Old case of gunstock deformity and almost complete loss of 
function of elbow due to fractures above and below the joint. X-ray examination shows 
supracondylar fracture in lower end of humerus and fracture of ulna below coronoid 
process. 

stability of the elbow is more completely destroyed in these types 
than in other forms of fracture in the lower end of the humerus. 
The traumatic reaction is usually severe and the fracture is not 



136 



FRACTURES AND DISLOCATIONS 



infrequently compound. On palpation crepitus is readily recog- 
nized, and when the comminution is extensive the region of the 
elbow may give one the sensation of a sack of marbles. When the 
condition is compound the wound is not infrequently located just 
above the olecranon on the posterior aspect of the arm. 

Fracture limited to the capitellum is extremely rare and presents 
no characteristic symptoms. Local tenderness and pain with use 
of the elbow are present, but the condition is seldom recognized 
without the aid of the X-ray. 





Fig. 199. 

Figs. 198 and 199. — Old case of dia^ondylar fracture with the usual backward dis- 
placement of elbow. Deformity closely resembles backward luxation of the eibow. The 
characteristic depressions at the back 'of the elbow are absent and palpation of the sig- 
moid determines that it is not empty. (Compare with Figs. 225 to 230.) 

Diagnosis. — The diagnosis of fractures of the lower end of the 
humerus is based on the symptoms just enumerated. Swelling 
about the elbow is usually rapid in onset and pronounced following 
fractures in this region, and the earlier the surgeon sees the case 
after the accident the less difficulty there will be in establishing a 
diagnosis. Firm, local, gentle and continued pressure in a given 



FRACTURES OF LOWER END OP HUMERUS 



137 



spot will iu many cases so displace the fluids within the swollen 
tissues as to render recognition of the underlying bone possible. 

If there is difficulty in determining the nature of the fracture the 
examination should be systematically conducted so that all the data 
possible may be gathered before the surgeon forms an opinion of 
the condition. If the traumatic reaction is pronounced it will 
usually be advisable to anesthetize the patient before examining the 
parts. The expense of repeated Rontgenographic examinations is 
frequently objected to by the patient, and under these circumstances 
it may be advisable to learn all that is possible from a physical 




Fig. 200. 



Fig. 201. 



Fig. 200. — Examination of three bony prominences with elbows acutely flexed. Note 
the slight backward and upward displacement of the patient's right internal condyle. 

Fig. 201. — With full extension it will he noted that there is a loss of carrying angle 
in the patient's right arm. The left arm is normal. Old fracture of lower end of right 
humerus. 



examination under anesthesia, reduce the fracture and then have 
an X-ray plate taken to verify the diagnosis and the completeness 
of reduction at the same time. A careful inspection of the parts 
is of the greatest value and should be done before the arm is sub- 
jected to any manipulation whatever. The character of the deform- 
ity and the attitude of the patient will often be sufficient to indicate 
the nature of the injury so that the diagnosis is confirmed by the 
least possible manipulation and palpation. The less the parts are 
disturbed and the more gentle the manipulation the better. If 
inspection indicates the nature of the injury the surgeon should 
examine the part suspected first. Otherwise the lower end of the 



138 FRACTURES AND DISLOCATIONS 

bone should be covered systematically. The external condyle 
should be palpated and note made of whether or not the process 
is continuous with the shaft of the humerus and the opposite con- 
dyle. The same examination should then be made of the inner 
condyle. The lateral stability of the elbow should next be tested 
with the forearm fully extended. In determining this point the 




Fig. 203. 



Figs. 202 and 203. — Old fracture of lower end of liumerus with union in deformity. 
Pronounced gun-stock deformity and shortening of arm. The positions of the three bony 
prominences have been marked and the displacement is apparent. A line drawn through 
the two condyles is not at right angles to the shaft of the humerus. By examining the 
elbow in this position one can tell the position which the forearm Avill occupy when 
extended. (See accompanying text.) Function good considering the deformity. Case 
first seen six years after the injury at which time these photogi'aphs were taken. 

lower end of the arm is • grasped above the elbow to steady the 
humerus while the opposite hand grasps the wrist and an attempt 
is made to adduct and then abduct the forearm. The wrist nor- 
mally moves inward in passing from the position of supination to 
pronation, and the distance traversed is nearly equal to the breadth 
of the wrist. This motion, however, is accomplished entirelj^ by 
the lower end of the radius encircling the head of the ulna and in 



FRACTURES OF LOWER END OF HUMERUS 139 

110 wise means lateral motion at the elbow. Lateral motion does 
not exist in the normal elbow. 

The relation of the three bony prominences of the elbow should 
be carefully noted, and if the normal relation is disturbed the 
surgeon should determine which of the prominences is displaced. 
The olecranon should be carefully palpated and its continuity with 




Fig. 204. — Another view of case shown in Figs. 202 and 203, showing the striking 
deformity. 

the ulnar shaft determined. The head of the radius should be 
palpated and note made of whether or not the head rotates with 
the radial shaft during pronation and supination of the forearm. 
The forearm should be carried through its normal range of motion 
and any restriction of action or pain should be noted. 

The backward displacement accompanying transverse fractures 



140 



FRACTURES AND DISLOCATIONS 



of the lower end of the humerus closel}^ resembles the deformity 
seen in backward luxations of the elbow. In luxations, however, 
the deformity is usually more pronounced and the sigmoid cavity 
is found empty on palpation (compare the appearances of the 
cases shown in Figs. 199 and 229). In fractures mobility is 
increased, while in luxations it is usually restricted. 




Fig. 205. — Fracture about two inches above the condyles Ihree years after the 
accident. Note the inAvard angular displacement of the lower fragment and resultant 
gun-stock deformity. Paralysis result of injury to musculo-spiral nerve at the level of 
the fracture. Nerve injury not recognized at the time of the inju.ry and nothing done 
subsequently to repair the damage. Patient has practically no use of the member. 
Cage first seen by author at time of taking this photograph. 



Fractures of the lower end of the humerus must be differentiated 
from 

Dislocations of the elbow. 

Dislocations of the ulna alone. 

Dislocations of the radial head. 

Fractures of the olecranon, 

Fractures of the coronoid and ulna below the elbow, 

Fractures of the radial head, neck, or shaft, 

Simple sprain of the elbow. 



FRACTURES OF LOWER END OF HUMERUS 



141 




Fig. 206. — Another view of case shown in Fig. 205. Patient cannot extend arm 
beyond position shown here. Note waist-drop, contracture and atrophy. 




Fig. 207. — Another view of case shown in Figs. 205 and 206. 



142 



FRACTURES AND DISLOCATIONS 




Fig. 208. — A rare case whicli demonstrates two deformities in the same patient. 
Both, arms were broken some years ago just above the elbow and both elbow joints were 
involved. After union had taken place the deformities were recognized. Valgus in one 
elbow and varus in the opposite. The left arm shows exaggerated carrying angle while 
the right arm shows "gun-stock" deformity. Case first seen by author 'at the time this 
picture was taken. Function in both arms fair considering the deformities. 




Fig. 209. — Picture taken to show how pronounced the normal carrying angle may 
be and the necessity of always examining the opposite elbovi'. (Left elbow has been 
painted with iodine following sprain.) 



FRACTURES OP LOWER END OF HUMERUS 143 

The reflexes and condition of the circulation below the level of 
the fracture should be tested both before and after reduction. The 
ulnar nerve is the structure most commonly injured, especially in 
fractures of the internal condyle, and its function should be most 
carefully tested. 

The value of the X-ray cannot be overestimated in the diagnosis 
of fractures of the lower end of the humerus and should be made 
use of whenever possible. The plates taken should be at right 
angles to each other or else made stereoscopically. 

Treatment. — An accurate appreciation of the nature of the 
fracture is essential to the intelligent treatment of fractures of the 
lower end of the humerus. As a rule anesthesia should be employed 
in reducing the displacement and in fixing the arm. Reduction is 
easily accomplished in many cases, yet it is not uncommon to 
encounter a condition in which reduction and fixation can be had 
only with open treatment. Transverse fractures can usually be 
reduced by grasping the lower end of the arm above the elbow to 
steady the humerus, and then making traction in the axis of the 
semiflexed forearm. This pulls the bones of the forearm forward 
and with them the lower fragment seated in the sigmoid cavity of 
the ulna. When the fragment has been brought back into position 
the elbow is flexed and immobilized in this position. Treatment of 
these fractures in acute flexion will give the best results in the 
greatest number of cases, yet the value of this position should not 
be overestimated nor should it be employed blindly. The best 
position in which to treat fractures of this region is the position 
w^hich will most accurately and securely maintain reduction, and 
just which position this is must be determined in each and every 
case to the satisfaction of the surgeon. Much has been said and 
written of the value of the three bony prominences in the diagnosis 
of fractures about the elbow, yet their chief value lies in the treat- 
ment of these conditions and seems to have been overlooked. A 
careful consideration of these three points with the elbow flexed 
will enable the surgeon to determine the position the forearm will 
occupy when extended. This determination is made in much the 
same manner as one would foretell the position a door would 
occupy when open, by a study of the position of the hinges when 
closed. This point is well illustrated in Figs. 202 and 203. In 
reducing a fracture in this region the surgeon should have the two 
condyles directly under his touch, so that he may follow the effect 



144 FRACTURES AND DISLOCATIONS 

on the fragments as the forearm is slowly carried through flexion 
and extension. The degree of flexion in which the fragments seem 
to occupy a position nearest to normal should be maintained, and 
dressings then applied which will immobilize the elbow. The two 
condyles should be in a line at right angles to the axis of the shaft 
of the humerus, and neither should occupj^ a position anterior to 
the other (taking the posterior surface of the humerus as a base). 
The tip of the olecranon should be at about the same level as the 
condAdes if extension is complete, at the apex of an equilateral 
triangle in acute flexion and j)roportionately situated between these 
two points in the various degrees of flexion. It will usuallj^ be 
found that posterior displacement of the lower fragment is cor- 
rected, more or less completely, by acute flexion, and we therefore 
seldom find the extended position available in the treatment of 
these cases. An arm may appear well reduced in the flexed 
position, and the surgeon may be pleased with the outlook of the 
case, and yet after union has taken place, the splints removed and 
the arm extended, a condition such as shown in Fig. 203 may become 
evident, to the chagrin of the surgeon and the dissatisfaction of the 
patient. Such results might be avoided by a careful examination 
of the three bony prominences following reduction as described 
above. 

In the treatment of vertical fractures involving the articular 
surfaces similar principles are to be followed out. Acute flexion, 
however, is not nearly as efficient in preventing recurrence of de- 
formity in these vertical fractures as it is when the break is trans- 
verse. During reduction lateral pressure should be made on the 
fragments in order that they may be forced closer together. Meas- 
urements of the distance between the two condyles should be made 
following reduction and compared with the opposite elbow. In 
some instances a detached condyle may follow the movements of 
the forearm during flexion and extension, and when this occurs the 
elbow should be fixed in the degree of flexion in which the fragment 
occupies a position nearest. to normal. If the fragment is rotated 
it may be necessary to operate to effect reduction. It should be 
remembered that the displacing action of the muscles of the fore- 
arm attached to the condyles varies with the degree of flexion of 
the elbow. In acute flexion the pull is upward and forward, in 
semiflexion it is forward, while in complete extension it is down- 
ward. 



FRACTURES OF LOWER END OF HUMERUS 145 

The principles involved in the treatment of epiphyseal separa- 
tions are the same as those given in the treatment of fractures of 
the corresponding parts. 

Special padding of the splint may be of aid in retaining the frag- 
ments though it is not so satisfactory a method as might be 
desired. Displacement depends somewhat on the extent to which 
the intermuscular septa and fasciag have been torn, and accordingly 
we experience less difficulty in those cases in which the damage 
sustained bv these tissues has been sli^'ht. 




Fig. 210. — Method of fixing the arm iu a position short of acute flexion for the 
treatment of certain fractures at the elbow. This method is far better than passing 
adhesive about the wrist and upper part of the arm as is commonly done. 

Fractures entering the articular surfaces demand the most accu- 
rate reduction. Perfect apposition means a small callus and is 
essential to restoration of joint function. 

The dressings employed to fix the part vary with the degree of 
flexion in which the elbow is immobilized. In cases in which the 
traumatic reaction is pronounced it is advisable to delay the appli- 
cation of dressings until it has subsided. During this time the 
patient should be in bed, the injured arm supported on a pillow and 
the ice cap applied at intervals. 

If the position of acute flexion is to be employed layers of 



146 



FRACTURES AND DISLOCATIONS 



gauze should be placed in the bend of the elbow, and in the axilla, 
to absorb the secretions and prevent chafing of the skin. The inner 





Fig. 211. Fig. 212. 

Fig. 211. — Internal right angle Dupuy splint. 
Fig. 212. — External right angle Dupuy splint. 

surface of the arm and forearm should be prevented from coming 
in contact with the chest for the same reasons. This is accomplished 
by layers of gauze appropriately placed. The usual method of 





213. 



Fig. 214. 



Fig. 213. — Internal, right-angle splint padded and secured in position with four 
strips of adhesive plaster. 

Fig. 214. — Method of securing traction with right-angle splint and weight. Seldom 
advisable. (See text.) 

maintaining acute flexion by means of a strip of adhesive binding 
the wrist to the upper part of the arm, is mechanically cumber- 



FRACTURES OF LOWER END OF HUMERUS 



147 



some and productive of discomfort. The most satisfactory method 
of securing the upper extremity in this position is shown in Fig. 
210. A strip of adhesive encircles the wrist and passes over the 
shoulder of the same side. In this way any position from semi- 
flexion to the most acute flexion may be had, and the amount of 
flexion may be increased from time to time during the subsidence 
of the swelling with the least possible disturbance of the elbow. If 
additional security is desired the axillary pad may be employed as 
described in the ''Treatment of Fractures of the Upper End of 
the Humerus" on page 99. A body swathe may be used to secure 
the arm to the side. 




Fig. 215. — Plaster splints 
of adhesive plaster. 



applied to upper extremity and held in position by straps 



If a position of semiflexion is chosen in which to immobilize the 
elbow the ordinary right angle splint may be employed. Either 
an internal or an external right angle splint will accomplish the 
purpose, though the former is usually preferable. This splint 
should be secured to the arm first by strips of adhesive, and then 
fastened to the forearm while traction is being made on the wrist 
to draw the fragment forward. 

When it is necessary to immobilize the forearm in positions 
between complete extension and semiflexion, plaster splints will 
usually be found most satisfactory (see Fig. 215). 



148 FRACTURES AND DISLOCATIONS 

Any form of splint applied to the upper extremity should be 
well padded with sheet cotton, and the encircling bandages or strips 
of adhesive used to secure it in position should not be so tightly 
applied as to cause constriction of the member. This precaution 
is of the greatest importance during the onset of swelling and if 
not observed may result in great damage. A dressing may fit 
properly at the time of application and yet a few hours later may 
be causing serious constriction. After the height of the traumatic 
reaction has passed and the size of the arm and forearm is dimin- 
ishing, snug bandaging will often accomplish much in reducing 
the swelling. 



Fig. 216. 




Fig. 217. 

Figs. 216 and 217. — Two types of adjustable splints for use in fractures about the 
elbow. 

Operative Treatment. — The open method is productive of the 
best results in many cases and we should not hesitate to resort to it 
when the proper surgical facilities are available and the ordinary 
methods are not efficient. No surgeon should operate on the lower 
end of the humerus without having well in mind the details of the 
anatomy of the region. The bone is peculiarly shaped, and without 
an accurate knowledge of its formation and the structures surround- 
ing it, the surgeon may do more harm than good. There is con- 
siderable compact tissue in the region of the condyles and above 
them in the shaft, but the bony structure supporting the articular 
surfaces is altogether cancellous. In order to acquire a good appre- 
ciation of the internal structure of the bone it will more than repay 
the student to open a humerus in coronal and sagittal section, using 
an ordinary hack-saw for the purpose, after which he may study 
the nature of the bone structure with which he has to work. In 
placing wire or nails we should rely as much as possible on the 
compact tissue ; a knowledge of its disposition and density will be of 
the greatest value. 

It is better to approach the fragments through an internal longi- 
tudinal incision or an external longitudinal incision or both, and 



FRACTURES OF LOWER END OF HUMERUS 



149 



to avoid, as mucli as possible, injury to the soft tissues about the 
joint. In this regard it shoukl be remembered that the musculo- 
spiral nerve and its branches descend obliquely between the 
supinator longus and the brachialis anticus on the outer side of the 
elbow, and that the ulnar nerve follows an almost vertical course 
and passes directly behind the prominent internal epicondyle. The 
external incision is best made behind the musculo-spiral, and the 
internal incision slightly anterior to the ulnar nerve and posterior 




Fig. 21 



Fig. 218. — Vertical fracture of lower end of humerus. Capitellum included in frag- 
ment which is displaced downward and rotated. When an attempt is made to flex arm 
the edge of the fragment threatens to penetrate the skin. Fragment nailed in position 
at operation and fracture treated in a position of semiflexion. X-ray by H. G. Stover. 

Fig. 219. — Same case five years later showing nail in place, fragment in reduction 
and carrying angle restored. Note the callus at upper end of fracture. Nail has not 
loosened and bony tissue next to nail shows no changes. Restoration of function com- 
plete. Injured member as useful and strong as opposite arm. X-ray by S. B. Childs. 



to the brachial artery and median nerve. If the elbow is ap- 
proached through either of the above incisions the median nerve 
will not be in the field of operation. 

After the bone has been exposed an analysis of the line or lines 
of fracture should be made, together with a consideration of the 
forces preventing reduction. The points of advantage for the 
placing of fixation materials are determined and the fragments 
reduced. A single nail will sometimes accomplish all that is re- 
quired (see Fig. 219), while in other cases it will tax the ingenuity 



150 



FRACTURES AND DISLOCATIONS 



of tlie most capable to secure the fragments. A T-fracture may 
sometimes be securely held by a through and through wire, while 
in other instances a circular wire may be made to bind two or more 
fragments together. In comminuted conditions it may be possible 
to secure one or more large fragments to the shaft, or to bind the 
fragments of the lower end of the bone together by a wire above the 
condyles, and then accomplish the balance of reduction by acute 
flexion. While the bone is exposed the elbow should be carried 




Fig. 220 



Figs. 220 and 22.1. — Same case as seen in Figs. 218 and 219 showing range of 
motion at elbows and normal carrying angle. Note the normal relations of the three 
bony prominences when the elbows are fully flexed. 



through flexion and extension to determine the position Avhich tends 
least to displace the fragments, and this position should be main- 
tained in the after-treatment. Care should be taken not to enter 
either the olecranon or coronoid fossa with nail or w^ire, as this may 
be an obstacle to flexion or extension after recovery. Provision 
for the escape of blood and exudates should be made by leaving a 
small drain of silk w^orm gut, which is to be removed in from 
twent3^-four to forty-eight hours. 



FRACTURES OF LOWER END OF HUMERUS 151 

The lower end of the humerus not infrequently presents conditions 
of fracture as difficult to handle as any other bone in the body. 

After-Treatment.— During the early part of the after-treatment 
the arm should be most carefully watched to avoid constriction. 
The dressings should be inspected at least daily to see that they 
remain in proper position. The axilla and bend of the elbow are 
points likely to show irritation of the skin and require special 
attention. If a posterior splint is employed the point of the elbow 
may need special padding to avoid undue pressure. If acute 
flexion is the position holding the fragments in reduction it should 
be increased as the swelling subsides and the danger of constriction 
grows less. 

The production and ossification of the callus is rapid about the 
elbow, and passive motion and massage should be begun at the 
earliest possible moment consistent with immobilization of the frag- 
ments. Gentle massage may be begun soon after the subsidence of 
the traumatic reaction provided care is taken to avoid disturbing 
the fragments. Gentle passive motion may be instituted in most 
eases at the end of from three to five weeks according to the age of 
the patient. Certain cautions should be noted, however, as much 
harm may be done by injudicious motion. The movements should 
be most guarded and gentle when first begun, and the condyles 
should be under touch of the surgeon to see that movement of the 
lower fragment is not produced. Motion should in no case be 
carried far enough to produce pain, which may be taken as an indi- 
cation that more harm than good is being done. Many surgeons 
prefer to delay passive motion until union is firm (four to six 
weeks or even later) and then if necessary the adhesions of the joint 
may be broken up under anesthesia. In some cases it will be neces- 
sary to anesthetize the patient a number of times, at intervals of a 
week or ten days, to keep the joint surfaces free until they are 
thoroughly healed. During the intervals the elbow is immobilized 
to allow the accompanying traumatic inflammation to subside. 
Such a procedure is tedious to both patient and surgeon but the 
subsequent results usually more than compensate for the additional 
trouble. 

The arm should be watched most carefully during the first ten 
days to avoid constriction on the one hand and loosening of the 
splints on the other. Strangulatioii of the limb is more likely to 
occur when the arm is maintained in a position of acute flexion. 



152 FRACTURES AND DISLOCATIONS 

while slipping of the splints is most often seen in positions between 
semi-flexion and extension. An arm should never be bandaged in a 
more or less extended position and then flexed, as constriction at the 
elbow is sure to take place. The plaster cast is a most dangerous 
dressing, especially if employed in the early part of the after- 
treatment. Its rigidity does not allow for the swelling of the mem- 
ber and may be followed by damaging constriction and Volkmann's 
contracture. When the internal or external angular splint is used 
it should be fixed with adhesive plaster in at least three places as 
shown in Fig. 214. If doubt exist as to the progress of union an 
X-ray plate should be taken. If the callus is heavy enough to 
throw a shadow it will usually be safe to employ passive motion. 

The removal of the splints or dressings should be gradual; that 
is, they should be removed for an hour or two each day, gradually 
increasing the time until they are permanently removed at the 
end of a week. A sling should be used for some time following 
removal of the splints. Exercise is to be gradually instituted, 
taking as a guide the fatigue produced. There should be no sense 
of fatigue after half to three quarters of an hour following exercise. 
It should be remembered that the most valuable and useful part of 
the function of the elbow joint lies in the range of motion included 
between acute flexion and semi-flexion. 

Prognosis. — The prognosis in fractures of the lower end of the 
humerus varies with the age of the patient, the severity of the 
lesion and whether or not the fracture enters the joint. Loss of 
motion in the elbow has been an unfortunately common sequel to 
fractures in this region, but with the advent of improved treatment, 
especially the open method, the number of cases of stiff elbow is 
being materially reduced. If the usual case of fracture of the lower 
end of the humerus is treated by the open method, the fragments 
accurately reduced, internal fixation employed and early passive 
motion instituted, the result will almost invariably be a functionally 
perfect joint without deformity. The prognosis is of course equally 
good in cases in which accurate reduction can be accomplished with- 
out operation, but the X-ray is continually demonstrating the fact 
that these cases are less numerous than was formerly supposed. 

Surprisingly good function often follows these fractures in 
children, even when deformity and non-union are present. Dis- 
turbances in the longitudinal growth of the bone in epiphyseal sep- 
arations are very unusual, being seen only in instances in which a 



FRACTURES OF LOWER END OF HUMERUS 153 

portion or part of the epiphysis is widely separated from the 
diaphj'sis. The bad prognosis so frequently given in text-books is 
based on the frequency of incomplete reduction and the common 
practice of prolonged immobilization. 

For the surgeon's protection, however, he should be quite guarded 
in the forecast given the patient or his family even when the case 
is uncomplicated. One never knows what complications may arise 
during the course of the case, and it has not uncommonly happened 
that the surgeon found that he had to deal with the exceptional 
case after a most favorable prognosis had been given. The outlook 
in compound cases is of course worse, yet if the principles laid down 
in the chapter on ''The Treatment of Compound Fractures" (page 
789) are followed out a large percentage of these open cases may be 
made to result as favorably as simple fractures in this region. 

The unfavorable results following fractures of the lower end of the 
humerus are: Volkmann's contracture, flail-elbow resulting from 
non-union ; cubitus varus, cubitus valgus, backward displacement of 
the lower fragment, and loss of motion varying in different cases 
from a solid ankylosis to a slight restriction of either complete flexion 
or extension. Volkmann 's contracture is a most disabling condition 
notwithstanding the fact that some improvement may follow opera- 
tion to liberate the nerves. This complication will not develop unless 
the arm has been unduly constricted by the dressings during the 
after-treatment. A flail-elbow will not follow if accurate reduction 
has been accomplished and, when present, may be corrected by a 
secondary operation. Cubitus varus and valgus are not as a rule 
productive of much disability. When pronounced, however, they 
may materially weaken the elbow and render the patient conspicuous 
on account of the deformity. Complete loss of motion in the elbow 
is rare. Loss of complete extension or acute flexion is common, 
though the disturbance in function is usually so slight as to be un- 
noticed by the patient. Sixty degrees of motion at the elbow will 
give the patient a serviceable joint even though the action is much 
less than the normal range of motion. The sooner the fracture is 
reduced the less marked will be the traumatic reaction. 

In compound suppurating cases the outlook is of course gloomy, 
especially when the fracture enters the joint cavity, yet it should 
not be forgotten that union may be obtained even in the presence 
of pus if free drainage is provided for. Much may be done in 
ankylosis by arthroclasia and arthroplasty. 



CHAPTER X. 

DISLOCATIONS OF THE ELBOW. 

Under this heading are included only the luxations in which both 
bones of the forearm are displaced on the humerus. Luxations of 
either the ulna or radius alone will be taken up later. 

Surgical Anatomy. — Much that has been stated under the head- 
ing of "Surgical Anatomy" in "Fractures of the Lower End of 
the Humerus" applies equally well in dislocations of the elbow (see 
page 120). 

The bones entering into the formation of the elbow joint are the 
humerus above, and the radius and ulna below. The articulation 




Vig. 222. Fig. 223. 

Fig. 222. — Ligaments of elbow from radial side. H., Humerus; R., Radius; TJ., 
Ulna: O.L., Olecranon; E.L., External lateral ligament; O., Orbicular ligament. 

Fig. 223. — Another view of the elbow. T., Tuberosity of radius; O.L., Oblique 
ligament; O., Orbicular ligament. 

betw^een the humerus and ulna is of the ginglymus or hinge type. 
The articulation between the humerus and the head of the radius is 
of the ball-and-socket type, though the attachments existing between 
the bones of the forarm necessitate the radius following the ulna in 
flexion and extension of the forearm. The strength of the elbow, 
especially its lateral stability, depends on the humero-ulnar articu- 

154 



DISLOCATIONS OF THE ELBOW 155 

latioii aud the lateral ligaments of the elbow. The internal lateral 
ligament consists of two divergent bands arising from the epitroch- 
lea ; the anterior band is attached to the inner side of the coronoid 
and the posterior band to the inner side of the olecranon, posteriorly. 
The external lateral ligament is similar to the internal; it is com- 
posed of tAYO bands arising from the epicondyle. The anterior band 
passes downward and forward, blends with the orbicular ligament 
and is attached just in front of the lesser sigmoid cavity of the ulna. 
The posterior band blends with the orbicular ligament, passes behind 
the head of the radius and is attached behind the lesser sigmoid cav- 
ity. Extension of the elbow is limited by the anterior portion of 
the capsule, by the anterior bands of the lateral ligaments, by the tip 
of the olecranon coming in contact with the bottom of the olecranon 
fossa, and by the tension of the biceps and brachialis anticus. 
Flexion is limited by the arm coming in contact with the forearm, 
b}' tension on the posterior bands of the lateral ligament, and by 
seating of the coronoid process in the fossa of the same name. In 
the usual dislocation of the elbow the orbicular ligament remains 
intact and the radius is displaced with the ulna. The overwhelming 
majority of luxations of the elbow are of the backward type and are 
usually produced by forced hyperextension of the joint. If the 
ligaments prove stronger than the lower end of the humerus, frac- 
ture is the result ; if not, luxation of the elbow is produced. 

The bones of the forearm may be displaced in any direction, and 
accordingly the luxations occurring at the elbow have been classified 
as follows: 

Backward (common). 

Outward (next in order of frequency). 

Inward (rare). 

Forward (rare). 

Divergent, antero-posteriorly (very rare). 

Divergent, laterally (very rare). 

Dislocation of the bones of the forearm from the humerus must 
of necessity be accompanied by extensive ligamentary tearing ; the 
lateral ligaments being the ones usually suffering most extensive 
laceration. It not infrequently happens that a given ligament is 
stronger than the bone to which it is attached, and accordingly frac- 
ture is not an uncommon complication of dislocations of the elbow. 
The external condyle may be broken off and the fragment remain 



156 FRACTURES AND DISLOCATIONS 

attached to and displaced with the radius. The epitrochlea is even 
more commonly aviilsed and displaced by the action of the internal 
lateral ligament, and the detached fragment may act as an obstacle 
to reduction by becoming interposed between the trochlea and 
sigmoid cavity. The periosteum is probably always more or less 
stripped up from the posterior surface of the humerus, the pull 
being transmitted through the posterior ligament. When the liga- 
ment proves stronger than the bone the olecranon process may be 
fractured. This stripping up of the periosteum accounts for the 
deposit of bony tissue seen on the posterior surface of the humerus 
following backward luxations. Fracture of the radial head or neck 
may occur as a complication in luxations of the elbow, and fracture 
of the shaft or lower end of the bone has been noted. Probably the 
most common fracture occurring in dislocations of this joint is that 
of the coronoid. This process is broken off as the ulna is driven 
backward across the trochlea. The brachialis anticus is attached to 
the anterior surface of the coronoid, and when the fragment is 
displaced upward it is usually tilted so the anterior surface looks 
more nearly in an upward direction. Instances of this complicating 
fracture are shown in Figs. 240 to 244. 

Injuries to vessels and nerves are fortunately seldom seen except 
in the most severe compound luxations. The median and musculo- 
spiral nerves are known to have been injured by the lower end 
of the humerus projecting into the bend of the elbow anteriorly. 
The ulnar nerve may be injured as it passes behind the epitrochlea, 
especially when this process is fractured or in the rare anterior 
luxation. Cases of laceration of the brachial artery are on record, 
but are extremely rare. 

Hyperextension, forced abduction or adduction, and wrenches and 
twists of the forearm are the types of violence usually responsible 
for luxations of the elbow. 

Symptoms. — Pain, tenderness, loss of function, restricted mobility 
and swelling of the parts about the elbow are symptoms common to 
all types of luxation of this joint. The patient is unable to use the 
forearm following injury (usually a fall on the outstretched hand) 
and complains of pain which is greatly increased on motion. The 
elbow is usually restricted in motion, especially flexion, but there 
may be some abnormal lateral mobility. There is no true crepitus 
unless fracture complicates the luxation. The degree of swelling 
is variable though it usually appears promptly and is frequently 



DISLOCATIONS OF THE ELBOW 



157 



pronounced. The relation of the three bony prominences is dis- 
turbed (except in anterior luxation with fracture of the ulna) and 
on examination the olecranon will be found to be the displaced ele- 
ment. The displacement of the ulna varies with the type of luxa- 
tion. 

The attitude of the patient is suo^gestive of the lesion, though by 




Fig. 224. — Simple backward dislocation of elbow a few minutes after the accident. 




Fig. 225. — baunj case seen from Ijehind. 

no means as characteristic as in luxations of the shoulder. In the 
posterior luxations the injured member is usually allowed to hang- 
uselessly at the side, or is rested on some convenient support such 
as a table. In the lateral or forward dislocations with fracture, the 
injured arm is, as a rule, supported by the opposite hand and the 
patient is reluctant to release it for examination. Deformity is the 
symptom which varies most in the different types of luxation. 



158 



FRACTURES AND DISLOCATIONS 



The posterior variety is by far the most common dislocation at 
the elbow, and is well represented by the cases shown in Figs 224 
to 230. The forearm is usually in a position between complete 
extension and semiflexion, and motion in either direction, beyond a 
few degrees, is painful and restricted both by spasm of the muscles 
and the disturbed mechanism of the joint itself. The olecranon is 
raised above its normal level, and more prominent than it should 
be. The tendon of the triceps stands out prominently, and the fore- 
arm is shortened. Inspection of the forearm at the elbow often 




Fis. 22 6. 



Fig. 2^ 



Figs. 226 and 227. — Additional views of the same case. Xote the prominence of 
the triceps tendon in the picture to the left and the gun-stock deformity in the picture 
to the right. This picture calls attention to the fact that gun-stock deformity may 
exist in dislocations of the elbow as well as in fractures of the lower end of the humerus. 



shows that it is rotated slightly inward and displaced outward (see 
Fig. 230). This rotation is due to the fact that the inner lip of the 
trochlea projects downward further than does the external lip, and 
thus pushes the ulna to the radial side, when the projection is no 
longer received in the cavity of the sigmoid. The lateral stability 
of the elbow is not, as a rule, so much impaired as in fractures of 
the lower end of the humerus. In palpating the elbow in backT\^ard 
dislocations, the fingers may be pressed into the empty sigmoid 
cavity of the ulna and the thumb may be placed in the shallow 
depression on the head of the radius, as shown in Fig. 229. The 
joint is painful as long as it is out of position, yet the pain is only 
intense when the elbow is moved. This displacement is probably 
not as painful as dislocation of the shoulder. The coronoid process 



DISLOCATIONS OF THE ELBOW 



159 



(unless broken off) rests behind the trochlea, and if the elbow is 
much extended it enters the olecranon fossa. The head of the 
radius lies behind the capitellum. 




Figs. 228 and 229. — ■Simple backward dislocation of the ' elbow about half an hour 
following the accident. Note the depression or dimple behind the elbow which is char- 
acteristic of this condition. Compare this case with Figs. 188, 189, 198 and 199. Fig. 
229 shows palpation of same case. The tip of the thumb rests in the depression on^top 
of the head of the radius. The sigmoid cavity of the ulna lies between the thumb 
and index fing'er of the examining hand and is felt to be empty. The leverage of the 
triceps is increased while that of the biceps is lessened and hence the position of least 
pain is greater than semiflexion. 



Lateral dislocations of the elhoiv may be divided into internal and 
external. External lateral dislocations may be complete or incom- 



160 



FRACTURES AND DISLOCATIONS 



plete, and there may or may not be an element of rotation present, 
as well as the lateral displacement. The incomplete external dislo- 
cation is the most common of the lateral displacements, but is much 




Fig. 230. — In backward luxations there is often a slight displacement of the ulna 
to the outer side which can be best appreciated by looking at the elboAV from behind. 
This element in the deformity is caused by the inner lip of the trochlea which is more 
prominent than the outer. Note the prominence of the triceps tendon and the depres- 
sions on either side of it. 




Fig. 231. 



Fig. 232. 



Figs. 231 and 232. — Outward dislocation of the elbow. The upper ends of the 
radius and ulna have been displaced outward and the forearm rotated so that the radius 
lies above the ulna. O., the position of the olecranon. T., the inner edge of the trochlea. 
Picture taken a few minutes following accident and the swelling is only slight. 

less frequently seen than the backward luxation just described. 
There is no hard and fast line between posterior and external lateral 
dislocations, which point should be remembered in dealing with 



DISLOCATIONS OF THE ELBOW 161 

luxations of the elbow. Cases are seen with backward dislocation 
accompanied by an external displacement, and cases of external 
dislocation are seen with an element of backward displacement, and 
it is difficult, in many cases, to say which element of the condition 
is more prominent. An arbitrary dividing line is considered by 
some to be the position of the coronoid ; if this process lies anterior 
to the trochlea the dislocation is lateral, but if it lies behind the 
trochlea it is posterior. Such a division makes the conditions fit the 
classification, rather than the classification fitting the condition. 

The external lateral dislocation is usually incomplete, the sigmoid 
of the ulna embraces the capitellum, and the head of the radius 
stands out externally; more frequently the head of the radius is 
raised above the level of the ulna and lies on, or close to, the 
epicondyle. This elevation of the head of the radius produces an 
inward rotation of the forearm, and the condition is spoken of as 
lateral dislocation with rotation or pronation. In other instances 
we find a complete external displacement of the bones of the fore- 
arm. In such cases the ulna has been carried further outward and 
rests on the surface of the epicondyle ; the radius may lie external to 
the ulna or above it, and accordingly we have complete external 
dislocation with or without rotation or pronation of the forearm. 
The ligaments are more or less torn according to the degree of dis- 
placement, but only in rare instances may the injury to the liga- 
ments (especially the anterior and internal) be considered slight. 
It is not uncommon to find the internal lateral ligament stronger 
than the bone to which it is attached, which accounts for the occa- 
sional fracture and outward displacement of the epitrochlea. This 
fragment may act as an obstacle to reduction by becoming inter- 
posed between the articular surfaces of the ulna and humerus. The 
elbow will be found broadened according to the degree of displace- 
ment. The relation of the three bony prominences is disturbed. 
The olecranon will be felt external to its normal position and the 
head of the radius located external to the epicondyle. The internal 
condyle is subcutaneous and very prominent, and the inner edge 
of the trochlea may be palpated below it, just under the skin. The 
epicondyle is not palpable because of the external displacement of 
the bones of the forearm. One not accustomed to these conditions 
of the elbow may become confused in attempting to identify the 
three bony prominences, and a diagnosis of fracture in such cases 
is common, when none really exists. 



162 FRACTURES AND DISLOCATIONS 

Internal lateral dislocation of the elbow is quite rare and only 
seen in the incomplete variety. The sigmoid of the ulna embraces 
the internal epicondyle, while the head of the radius is displaced 
more or less inward onto the outer portion of the trochlea. The 
forearm is inclined to a position of supination, and the olecranon is 
out of relation with the condyles of the humerus. Complications in 
lateral dislocations are extremely rare, and consist for the most part 
in fracture of the internal epicondyle . fracture of the external 
condyle has been reported. 

Forward dislocation of the eJhow is extremely rare and seems to 
be secondary to fracture of the olecranon. Fracture of this process, 
at the bottom of the sigmoid cavity, may result in the distal frag- 
ment of the ulna being driven upward in front of the humerus 
by the same force that produced the fracture. Complete anterior 
dislocation, without fracture of the olecranon, is so rare that it 
had better be considered an anomaly. The fractured olecranon 
may be recognized by palpation and the abnormally high position 
of the upper part of the forearm, and its change in axis may be 
determined without difficulty fsee Fig. 239). "When the olecranon 
is not fractured it either lies in front of the lower end of the 
humerus or (in the incomplete form) the end of the process rests 
on the trochlea, the lateral ligaments having suffered extensive 
laceration. 

Divergent dislocations of the elbow are very rare indeed, being 
usually the result of great trauma. They are sometimes seen in 
falls from a height and in severe machinery accidents. One reason 
for the rarity of these dislocations is that the arm is seldom caught 
in just such a manner as to tear both the heavy orbicular ligament 
and the interosseous membrane, and the force so directed as to 
displace the bones in different directions. There are two forms of 
divergent dislocation — antero-posterior and lateral. In the antero- 
posterior the radius lies anterior to the humerus, and the ulna 
behind it. The posterior aspect of the elbow resembles quite 
closely the simple posterior variety of dislocation, the point of 
differentiation being the presence of the head of the radius in front 
of the elbow. The lateral variety is so rare that few cases have 
been reported. The ulna lies to the inner side of the humerus, 
while the radius is displaced externally, and the elbow is accordingly 
increased in breadth to nearly twice that of normal. 

The symptoms produced by injury to nerves or vessels will depend 



DISLOCATIONS OF THE ELBOW 163 

on which of these structures has been damaged. The paralyses or 
disturbances in circulation are the same as follow injury to the 
nerves and vessels of the upper extremity from causes other than 
dislocation of the elbow. 




Figs. 233, 234 and 235. — Diagrams showing the bony relations in the three most 
common injuries at the elbow. The npper diagram is of a posterior dislocation. Note 
the empty sigmoid cavity. The middle drawing is of a dia-condylar fracture while the 
lower is of a supracondylar fracture. There is no hard and fast line between the supra- 
and dia-condylar fractures yet the terms are used to indicate the level of the break. 

Diagnosis. — The recognition and differentiation of the various 
types of luxation of the elbow are made on the SA^mptoras just 
described. In establishing a diagnosis of dislocation of the elbow 
the surgeon must keep in mind — first, the bony lesions which are 



164 FRACTURES AND DISLOCATIONS 

most commonly mistaken for luxation; second, the complicating 
fractures which sometimes accompany dislocations; and third, the 
complicating lesions of the soft tissues, such as injury to vessels 
and nerves. The condition most frequently confounded with dislo- 
cation is fracture or epiphyseal separation of the lower end of the 
humerus. In fracture of the lower end of the humerus with back- 
ward displacement, the sigmoid is not found empt}^ and it is 
impossible to feel the cup-shaped depression on the head of the 




Fig. 236. — Case of simple sprain of the elbow twenty-four hours after the acci- 
dent. Note the swelling which is as great as is seen following fracture or dislocation 
and materially interferes with examination and diagnosis. Note, however, that there is 
no ecchymosis which is so common in fractures, after the first twelve or twenty-four 
hours. 

radius as shown in Fig. 229. The backward displacement is usually 
less prominent in fractures, and the deformity is, as a rule, per- 
ceptibly higher. The relation of the three bony prominences is dis- 
turbed in vertical fractures of the lower end of the humerus, in 
dislocations of the elbow and in fractures of the olecranon, but not 
in transverse fractures of the lower end of the humerus. (See 
Figs. 233 to 235 and compare the deformities.) Dislocations of 
the upper end of the ulna alone are differentiated from luxations 



DISLOCATIONS OF THE ELBOW 



165 



of tlie elbow by the position of the head of the radius which remains 
in it-s proper rekition with the capitellum. 

To avoid mistakes it is well to identify the ulna at its lower end 
and trace the posterior subcutaneous border up to the olecranon; 
the head of the radius may next be identified and rotated by 
supinating and pronating the forearm. After these two points have 
been positively identified there will usually be little difficulty in 
recognizino^ the other landmarks of the elbow. When the case is 




Fig. 237. 



Fig. 237. — Case of lateral dislocation of the elbow twenty-four hours after injury 
and reduction. Note the swelling about the elbow. 

Fig. 238. — Same case after palpation of three bony prominences and marking same 
with ink. 



seen early a tentative diagnosis can, as a rule, be made by inspection 
alone, but if first seen after swelling has developed it may be quite 
difficult to examine and determine the condition. 

Gentle, firm and continued pressure with the fingers in the region 
of the condyles and olecranon will usually displace the fluids within 
the tissues sufficiently to allow the surgeon to determine the 
positions and conditions of the three bony prominences. An anes- 
thetic is often advisable if the traumatic reaction is pronounced at 
the time of the examination. An even better procedure under these 



166 



FRACTURES AND DISLOCATIONS 



circumstances (provided the deformity is not great and the X-ray 
is promptly available) is to leave the parts undisturbed and deter- 
mine the nature of the injury from a Rontgenogram. 




Fig. 239. — Anterior luxation of the elbow with fracture of the olecranon. (Small 
nails seen in plate are in splint.) 




Fig. 240. — A not uncommon complication of backward dislocations of the elbow. 
The coronoid process has been broken off and is displaced upward by the brachialis 
anticus. This muscle is inserted into the anterior surface as well as the tip of the 
process which accounts for the tipping of the fragment as it is pulled upward. 



Fracture of the coronoid is often difficult to recognize because 
of the swelling. It is frequently impossible to palpate the detached 



DISLOCATIONS OF THE ELBOW 



167 



particle of bone, and the fact that the fragment is usually displaced 
upAvard prevents crepitus. 

Complications are fortunately rare yet they do occasionally occur 
and should, if possible, be recognized before reduction. The 
diagnosis of these conditions is often made only after reduction 




Fig. 241. — Backward luxation fracture of the tip of the coronoid process. 
Fig. 242. — Backward luxation with comminuted fracture of coronoid process. 




Fig. 243. — Large fragment of coronoid displaced upward by action of biceps, 
ture result of backward luxation of elbow. 



Frac- 



Fig. 244. — Fracture of coronoid with only slight displacement, 
ward luxation of elbow. 



Result of back- 



has been attempted or accomplished, and many cases would go un- 
recognized if it were not for the X-ray. The condition of the 
reflexes and the circulation below the level of the lesion should be 
determined both before and after reduction. Kecurrence of de- 
formity following reduction is suggestive of fracture of the lower 
end of the humerus or of the coronoid process of the ulna. 

Treatment. — The treatment of dislocations of the elbow consists 
in returning the ulna and radius to their normal relations with 
the humerus, and immobilizing the elbow for a period sufficiently 
long to allow complete healing of the ligaments. The case should 
be attended as soon following the accident as possible. The longer 
the luxation exists the more difficult will be the diagnosis, the more 
painful the parts and the more pronounced the secondary traumatic 



168 



FRACTURES AND DISLOCATIONS 



reaction. Reduction of the dislocation is usually not difficult, and 
according to the most common method, consists (for backward 
luxations) in traction and counter-traction with hyper-extension 
of the joint followed by flexion. The arm is firmly grasped above 




Fig. 245. — Method of reducing backward luxation of the elbow. Traction on the 
forearm at the wrist with counter-traction with the opposite hand on the arm. A 
greater degree of extension is often necessary to help the coronoid to clear the trochlea. 




Fig. 24G. — Another method of reducing backward luxations of the elbow. The 
lower part of the arm is grasped with both hands as shown in illustration while the 
thumbs force the olecranon doAYuward. into position. With the hand fixed on the table 
any desired degree of flexion at the elbow may be obtained during the manipulation. 



the elbow with one hand while the other makes traction from the 
wrist ; during this traction the forearm is somewhat hyper-extended 
to allow the coronoid to clear the trochlea, after which the forearm 
is flexed and reduction is complete. The ligaments are usually torn 



DISLOCATIONS OF THE ELBOW 169 

to such an extent that they offer little resistance to reduction, but 
the muscles, especially in well developed persons, may as a result 
of spasm, render reduction extremely difficult. A method of reduc- 
tion, particularly adapted to children, consists in forcing the 
olecranon into place with the thumbs while the fingers fix the arm 
above the elbow as shown in Fig. 246. By having the patient's 
hand resting on a table flexion and extension may be controlled by 
raising or lowering the elbow during the manipulation, thus helping 
the coronoid to clear the trochlea. Still another method is one in 
which the joint surfaces are separated and flexion of the elbow 
accomplished over the operator's knee. Reduction may also be 
accomplished by means of continuous traction with weights, but the 
first method described will be found as satisfactory as any in the 
average case of posterior luxation. 

The muscles offer the chief obstacle to reduction and accordingly 
the use of an anesthetic will render difficult cases easy. The liga- 
ments are already much torn and we should avoid manipulations 
which will subject them to further injury ; this point should be kept 
well in mind when using an anesthetic, as the joint, under such 
conditions, is no longer protected by the action of the muscles. 
When the bones are displaced outward further than is caused by the 
internal lip of the trochlea (see Figs. 231 and 232), they should be 
converted into a simple backward dislocation before reduction is 
attempted. The less force used the better, and in a given case it 
is often preferable to try different methods with moderate force, 
before using any particular one with much force. There is probably 
no method, in backward dislocations of the elbow, which meets 
the indications as scientifically as does Kocher's in reduction of 
anterior luxations of the shoulder, yet the ones in use are effective 
and though not ideal are at least satisfactory. 

In reducing an outward luxation it is of the greatest advantage 
to have an assistant fix the lower end of the humerus, thus affording 
the surgeon a solid basis on which to force the bones of the forearm 
into position. Before reduction is attempted the surgeon should 
know whether or not rotation is present, as well as lateral displace- 
ment. With the lower end of the arm fixed, traction is made on the 
wrist, while the opposite hand grasps the elbow and forces the 
upper ends of the radius and ulna downward and inward around 
the lower end of the humerus. If the bones of the forearm are dis- 
placed backward as well as outward it may be advisable to accom- 



170 FRACTURES AND DISLOCATIONS 

plish. reduction as if the displacement were straight backward, with 
the addition of lateral pressure as the joint surfaces are being 
brought together. The most common obstruction to reduction is the 
lodgment of an epitrochlear fragment between the articular sur- 
faces. If the elbow is hyper-extended this fragment can as a rule 
be gotten out from between the articular surfaces. Downward 
traction on the semiflexed forearm with a rocking motion will some- 
times be effective in displacing the fragment. 

Reduction of an inwurd dislocation is accomplished in a manner 
similar to correction of the outward displacement except that out- 
ward pressure is exerted during traction, instead of inward pres- 
sure. There is usually little difficulty in reducing this type of luxa- 
tion. 

In forward luxations with the usual fracture of the olecranon, 
reduction is accomplished by downward pressure on the upper part 
of the semiflexed forearm, thus forcing the head of the radius back 
onto the capitellum and the ulna back into alignment with the frag- 
ment of the olecranon. In the rare instances in which fracture of 
the olecranon does not complicate the luxation, reduction is accom- 
plished by acutely flexing the forearm, and then forcing the tip 
of the olecranon past the trochlea by downward pressure. In the 
incomplete form of the dislocation, in which the olecranon lies on 
and not in front of the trochlea, this manipulation is fairly safe, 
but in the complete form there is grave danger of injury to the 
ulnar nerve. To lessen this danger the arm should be adducted 
until the olecranon has passed the trochlea. Complete forward 
luxation of the elbow is however extremely rare. 

In divergent luxations of the elbow traction is to be made on the 
extended forearm and each bone reduced separately. 

After reducing a dislocation of the elbow, regardless of the type, 
the joint should be carried through its normal range of motion and 
the parts carefully examined so that complications may not be over- 
looked. 

Operative Treatment. — Operation is indicated when, after 
repeated trials under an anesthetic, the joint remains displaced 
and in cases in which complications such as irreducible fracture or 
injury to vessels or nerves exist. The joint may be approached by 
an external longitudinal or an internal longitudinal incision, accord- 
ing to the preference of the surgeon and the conditions present. 
The ulnar nerve lies internal to the elbow behind the epitrochlea, 



DISLOCATIONS OF THE ELBOW 171 

while the miisculo- spiral descends behind the supinator longus as 
described in Operative Treatment of "Fractures of the Lower End 
of the Humerus ' ' on page 148, and should be protected from injury 
during operation. It may occasionally be necessary to divide some 
of the ligaments to replace the bones. The external condyle may be 
broken off and displaced backward with the radius, and if the frag- 
ment cannot be accurately reduced by manipulation it is advisable 
to secure it with a nail or wire. The internal epicondyle may be 
separated, and when the fragment becomes wedged between the 
articular surfaces it may be necessary to operate to release it and 
effect reduction. Not infrequently internal fixation is indicated to 
maintain reduction of the fragment when fracture complicates the 
luxation, and the principles involved are the same as have already 
been described under the heading of Operative Treatment of 
''Fractures of the Lower End of the Humerus" on page 148. Frac- 
ture of the coronoid is not an uncommon complication and may, as 
a rule, be successfully treated with the elbow in the flexed position. 
When, however, the fragment is large and the upward displacement 
is so pronounced as to prevent approximation by flexion, it will be 
advisable to operate and suture the fragment in position. Suture 
of the ligament and surrounding soft tissues will, as a rule, suffice 
in holding the fragment in place. 

Complicating fracture of the head of the radius does not call for 
operative intervention except in very rare cases. 

When fracture of the olecranon exists it may be difficult to keep 
the fragments in apposition ; open incision and internal fixation may 
be called for to secure proper reduction of the process. (See Oper- 
ative Treatment of "Fracture of the Olecranon," page 191.) 

The advisability of operating for the correction of old unreduced 
luxations depends almost entirely on the amount of function lost. 
If the patient is enjoying free use of the joint and the elbow is 
strong, it will be absurd to advise operation simply to correct the 
deformity. Operation for the correction of old displacements is 
performed according to the same principles, and the same precau- 
tions are to be observed, as already given in the open treatment of 
recent cases. A certain amount of fibrous tissue will usually be 
found within the sigmoid cavity and should be removed before the 
luxation is reduced. 

After-Treatment. — The after-treatment consists in immobilizing 
the joint sufficiently long to allow proper healing of the ligaments. 



172 



FRACTURES AND DISLOCATIONS 



In posterior luxations the anterior ligament is most extensively torn 
and the flexed position will be the one which will bring the torn 
ends nearest together; the same holds true when the coronoid has 
been fractured, therefore the best position will be found to be 
one just short of acute flexion. Complete flexion is a position which 
is quite uncomfortable and poorly adapted to the swelling of the 
elbow which is to follow, and for these reasons a position a few 
degrees short of complete flexion is advised. The arm and forearm 
should be bandaged in this position and the axilla protected to 



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fk V - 


^ 


■^^KBb n 


H^^^i^flK^ 




l^i^E 


k. ^ ^^R I^^^^Ih 


LI 


^^LjJE 


Kil^3^ 


vQ 


■■H 


II^H 


11 



Fig. 247. 



Fig. 248. 



Figs. 247 and 248. — These two figures show the range of motion fourteen days after 
a posterior luxation of the elbow. Note how the swelling has subsided as compared with 
the case seen twenty-four hours after the dislocation, as shown in Figs. 237 and 238. 



prevent skin coming in contact with skin, and some means of fixa- 
tion applied as has already been described under the head of "Frac- 
tures of the Lower End of the Humerus," page 210. Passive 
motion of the joint should not be begun until the acute traumatic 
reaction has fully subsided, which will be at the end of a week or 
ten days. This will allow some time for the capsule to heal, but 
immobilization should not be too prolonged, as unnecessary stiffen- 
ing of the elbow may result. Passive motion should not be delayed 
longer than two weeks and should at all times be gentle. When 



DISLOCATIONS OP THE ELBOW 173 

once begun it should be practised every two to four days until 
complete or nearly complete motion is regained. The use of hot 
applications and massage daily will hasten recovery. The carrying 
of weights will materially increase extension during the latter part 
of the after-treatment. The elbow will show more or less stiffness 
when the dressings have been removed and will remain so for a 
short time but this is no occasion for anxiety as function will return 
with passive motion, massage, and use of the arm. Complete 
extension will be the last to return and may never be fully regained 
if the periosteum on the back of the humerus has been extensively 
stripped up and followed by a deposit of new bone under it in the 
region of the olecranon fossa. The fixation does not need to be 
as absolute as is maintained in fracture, but should be kept up for 
two to three weeks, and action requiring much strength should be 
avoided for another two to three weeks. The attitude to be partic- 
ularly avoided is complete extension within a week of the injury, 
and this should be the last position in which muscular effort is per- 
missible, after the patient is again using the arm. 

Fixation in a position of supination will tend to relax the supina- 
tors and should be employed when complicating fracture of the 
external condyle or epicondyle exists. Flexion and pronation will 
relax the pull on the internal condyle and epitrochlea in the 
presence of fracture in this region. 

The after-treatment of forward dislocations is much the same as 
has already been described. The presence of complications, such 
as nerve or vessel injury, may necessitate operation. The ulnar 
nerve may be stretched or torn and require suture. 

The after-treatment of divergent dislocations is much the same 
as other dislocations about the elbow. The joint should be put at 
rest for a month to allow the ligaments to heal, but absolute fixa- 
tion is not as desirable as it is in fracture. It is well to fix the 
elbow in a posterior right angle splint for the first ten days to two 
weeks, after which a sling may be used which supports the entire 
forearm. After the splint has been removed gentle passive motion 
may be employed at intervals of four or five days, but should be 
painless. Some restriction of motion may follow the injury and 
subsequent immobilization, but this is better than a condition of 
recurrent dislocation. Accordingly, in view of the extensive injur}^ 
sustained by the ligaments and soft tissues, it is preferable to incline 
toward the safer course and not allow motion too soon. Extreme 



174 FRACTURES AND DISLOCATIONS 

extension should be avoided during passive motion and the patient 
should be warned against strain in this position for some months 
following the accident. 

Prognosis. — The prognosis in luxations of the elbow depends on 
the extent of laceration sustained by the ligaments and the presence 
of complications. The amount of damage to the ligaments is in 
direct proportion to the extent of displacement. In simple cases 
of posterior luxation we may look for complete restoration of func- 
tion if the after-treatment is properly carried out. The last few 
degrees of extension may be permanently lost, but this does not 
disturb the usefulness of the joint and is negligible. Extensive 
injury to the soft tissues and complicating fracture will, of course, 
render the prognosis more doubtful. 

Young persons make more rapid and complete recovery, while on 
the other hand those advanced in years (especially with rheumatic 
diathesis) are liable to be troubled with the joint for a long time. 
Fortunately the more common forms of dislocation are followed by 
useful and strong joints, if the ligaments are allowed time to heal. 
The dislocations that are accompanied by great laceration of the 
ligaments are most likely to be followed by weakness of the parts or 
recurrence of the displacement. Nerve injury accompanying the 
accident may be followed by paralysis and anesthesia, the same as 
nerve injury from other causes. Damage to nerves usually consists 
of simple stretching and is generally not severe. As a rule recovery 
takes place within a few months at most. Complete rupture of a 
nerve results in a permanent paralysis unless operated, and even 
then recovery may be extremely long and tedious. The ulnar nerve 
is most frequently involved, the musculo-spiral next, while the 
median nerve rarely suffers injury. Considering the frequency 
with which the elbow is dislocated injury to the nerves in this region 
is rare, and the ultimate prognosis, even in cases of complete sever- 
ance, is good, if the divided ends are brought together and properly 
sutured soon after the accident. 



CHAPTER XI. 
DISLOCATIONS OF THE ULNA ALONE (ROTARY). 

Surgical Anatomy. — The surgical anatomy of luxations of the 
upper end of the ulna alone, is similar to that already given in 
' ' Dislocations of the Elbow ' ' on page 154. Dislocations of this type 
are quite rare, whereas luxations of the elbow (both bones) are by 
no means uncommon. 

The upper end of the ulna may be displaced either backward or 
forward, describing the arc of a circle, of which the undisplaced 
radial head is the center. Both types are exceedingly rare, but of 
the two the posterior is the more common. In either form the inter- 
osseous membrane and oblique ligament are probably not torn, and 
the head of the radius remains in position on the capitellum. The 
injury is probably produced by trauma which twists the forearm at 
the same time adducting or abducting it. 

Symptoms. — The posterior variety presents a characteristic 
clinical picture. The forearm is more or less extended and there 
is a pronounced "gunstock deformity." The olecranon is promi- 
nent and raised, though the displacement is usually not as pro- 
nounced as seen in posterior luxations of both bones. The tip of 
the coronoid may rest on the trochlea, or behind it, or the upper end 
of the bone may be still further displaced so that it rests behind the 
external condyle. The further the backward displacement of the 
upper end of the ulna, the more external will be the position occu- 
pied by the olecranon and the more pronounced will be the cubitus 
varus. The epitrochlea is prominent and more anteriorly situated 
than normal, with relation to the forearm. There is a compensatory 
outward rotation of the humerus to accommodate the altered 
position of the forearm. The internal lateral ligament may be 
ruptured or an equivalent avulsion of the epitrochlea may exist. 

In forward luxations the ligamentary laceration, especially on 
the inner side of the elbow, is greater and the causative trauma is 
more severe. The forearm may lie anywhere between semiflexion 
and complete extension. There is abnormal lateral mobilit}^ in the 

175 



176 FRACTURES AND DISLOCATIONS 

direction of abduction. The top of the olecranon lies either on, or 
in front of, the trochlea and the position of the forearm is one 
of pronounced abduction. In other words, the carrying angle is 
greatly exaggerated. 

A third form of luxation, so rare as to scarcely deserve descrip- 
tion, is one of inward luxation. In this type the upper end of 
the ulna is displaced inward so that the sigmoid embraces the epi- 
trochlea, while the radius remains in contact with the capitellum. 
The interosseous membrane, oblique and orbicular ligaments are 
of necessity ruptured and the upper part of the forearm is greatly 
broadened. 

In all three forms of luxation of the ulna the head of the radius 
probably suffers a slight subluxation, but since it remains in contact 
with the capitellum it may for practical purposes be considered 
in normal position. 

Treatment. — In hackivard luxations reduction is easily accom- 
plished b}^ extension and counter-extension in much the same way 
as has been described in the "Treatment" of "Dislocations of the 
Elbow. ' ' The adduction, which is due to the radius remaining in 
place, must be taken into account and requires a forced abduction 
of the elbow as extension and counter-extension are being made. 

In forward luxations the ulna is returned to its normal posi- 
tion by inward rotation of the upper end of the forearm, accom- 
panied by adduction of the forearm as the olecranon clears the 
trochlea. 

The After-Treatment, Operative Treatment and Prognosis are 
similar to those already given under "Luxations of the Elbow," 
pages 170, 171 and 174. 



CHAPTER XII. 

DISLOCATIONS OF THE HEAD OF THE RADIUS. 

Surgical Anatomy. — The head of the radius may be likened to a 
short cylinder. The upper end of the cylinder articulates with 
the capitellum and is slightly concave. The sides of the cylinder 
are in contact with the orbicular ligament and lesser sigmoid cavity 
while the lower end of the cylinder is continued into the neck of 
the radius. The lower end is slightly less in diameter than the 
upper end of the cylinder, and the orbicular ligament thus secures 
a hold on the upper extremity of the bone which tends to prevent 
downward displacement. The interosseous membrane and the ob- 
lique ligament, together with the orbicular ligament, bind the 
radius to the ulna though they allow free motion in pronation and 
supination. The external lateral ligament of the elbow is not 
attached to the radius but divides and blends with the orbicular 
ligament, passes in front of and behind the radial head, and is at- 
tached to the ulna anterior and posterior to the lesser sigmoid 
cavity. The head of the radius articulates with the lower end of 
the humerus and with the ulna at the lesser sigmoid cavity. 

The radial head may be displaced : backward, outward, forward 
or downward. The exact mechanism of dislocations of the radius 
is not clear. The matters of importance are that the head is dis- 
placed and requires reduction. Fracture of the radial head or 
neck or of the upper end of the ulna may accompany the luxa- 
tion. 

Malgaigne's luxation (downward subluxation) has also been the 
subject of much discussion and there is little known concerning 
the mechanism of the injury. The consensus of opinion, however, 
is that there is a slight downward luxation of the radial head, and 
that there may be some infolding of the ligaments between the 
articular surfaces. This luxation is confined to children, usually 
under three or three and a half years of age, and is due to trac- 
tion in the axis of the radius. 

There is no hard and fast line to be drawn between outward and 

177 



178 FRACTURES AND DISLOCATIONS 

"backward luxations of the radial head, one form merges into the 
other. The relation between these two types is much the same 
as that already noted between backward and outward luxations 
of the elbow. Any form of isolated luxation of the radial head 
is rare as compared with luxations of the elbow. 

Symptoms. — In any t^^pe of luxation of the head of the radius 
there is pain in the region of the injury and loss of function im- 
mediately following the accident. The deformity will vary with 
the direction of the displacement. 

In the hackward or outward types the head is felt standing out 
in a position anywhere betAveen posterior and external to its normal 
position, and may be identified by the characteristic cup-shaped ex- 
tremity and by its rotation with the shaft during pronation and 
supination. The forearm is, as a rule, completely pronated and in 
a position just short of complete extension. Further examination 
shows that supination is checked by the altered mechanism of the 
joint, though strange to say this function seems to be regained in 
old unreduced luxations. 

In forward luxations the elbow is partially flexed and the fore- 
arm may be either supinated or pronated, usually the latter. Pro- 
nation is, as a rule, complete, and passive supination blocked. 
Flexion beyond a right angle is never possible in recent cases ; the 
head of the radius coming in contact with the anterior surface of 
the bone prevents flexion. Palpation of the forearm below the 
external condyle reveals the absence of the radial head from its 
normal position. The bend of the elbow is usually swollen and 
the displaced end of the bone may be palpated, though it is seldom 
as distinctly felt as is the case in backward and outward luxations. 
Old unreduced cases may show remarkable restoration of function 
as in the backward and outward types. 

Downward luxation is productive of xevy mild symptoms. The 
child flinches at the time of the injury and may cry out. Dis- 
inclination to use the arm is at once noted, the forearm being held 
in a position of slight flexion and complete pronation. The child 
suffers little or no pain as long as the elbow is not brought into 
play, and accordingly the patient is very averse to having the mem- 
ber examined or in any way disturbed. If it were not for this 
disinclination to use of the member, the injurv^ might frequently 
escape recognition. There is, as a rule, no deformity about the 
elbow to be appreciated by either inspection or palpation. In some 



DISLOCATIONS OF HEAD OF RADIUS 



179 




Fig. 249. — Forward luxation of the head of radius. Prominence indicated by arrow 
is caused by the displaced radial head. Note the exaggerated carrying angle which re- 
sults from the head of the radius not bearing on the capitellum of the humerjis. Flexion 
limited by the displaced radial head. 





Figs. 250 and 251. — X-rays of same case showing luxated radial head. 



180 FRACTURES AND DISLOCATIONS 

instances there may be a slight separation between the head of 
the radius and capitellnm but this is usually so trivial as to be 
scarcely perceptible. Loss of function may persist for a long time 
if proper treatment is not instituted, though ultimate disability 
of the member seldom occurs. 

Diagnosis. — The diagnosis of luxations of the radial head depends 
on the restriction of motion, the characteristic attitude and pal- 
pation of the head of the bone in its displaced position while the 
upper end of the ulna remains normally placed. The diagnosis 
of Malgaigne's luxation is based largely on the history of the case 
and the disinclination on the part of the child to use the member. 
The history is typical. The condition is the result of the per- 
nicious habit of lifting a child by the hand; mothers are prone to 
do this in helping children on and off of street cars, and in hurry- 
ing them along the street. Following injury to the arm in this 
way the child fails to use the member and objects to having it 
disturbed. 

The X-ray is of value chiefly in determining associated lesions, 
such as fracture of the radial head or neck or of the external con- 
dyle of the humerus, or a break in the ulna. 

Treatment. — Reduction in the backward and outward types is 
usually easy, though the head may tend to slip out again as soon 
as the arm is released. Retentive dressings should be in readiness 
before returning the head to its normal position. Extension and 
counterextension, accompanied by direct pressure on the head in 
the direction of the capitellum, will, as a rule, effect reduction. 
The degree of flexion in which there is least tendency for the head 
to slip out of position should be determined in each case and the 
joint immobilized in this position. A pad maintained in place 
by straps of adhesive and exerting direct pressure on the upper 
end of the bone may be of service in preventing recurrence of de- 
formity. The head of the bone may be fractured against the 
capitellum as it is driven out of place, and when this complication 
exists it may increase the tendency to reluxation. 

In forward luxations similar principles are employed. Reduc- 
tion is accomplished by extension, counterextension and direct 
backward pressure on the displaced head. When the head of the 
radius is felt to move backward the elbow is flexed and the ma- 
nipulation is complete. To prevent recurrence of deformity the 
elbow should be immobilized in a position just short of acute flexion 



DISLOCATIONS OF HEAD OF RADIUS 181 

(see Fig. 210). AVhen luxation of the radial head is complicated 
by fracture of the ulna, increased difficulty may be experienced 
in preventing- reluxation. In addition to treating the dislocation 
we have the fragments of the ulna to maintain in apposition. 
Under these circumstances internal and external angular splints 
will be found more efficient than the position of acute flexion ad- 
vised in the uncomplicated anterior dislocation. If the elbow is 
to be immobilized at a right angle the ordinary internal and ex- 
ternal angular splints will be satisfactory. If, however, some other 
degree of flexion is desired plaster splints may be needed. If 
ordinary means are not efficient in preventing deformity in either 
the fracture or the luxation operation should be resorted to. 

The reduction of Malgaigne's luxation is usually accomplished 
without difficulty. It consists in forcing the head of the radius 
upward against the capitellum, and is accomplished in the fol- 
lowing manner. The surgeon grasps the lower part of the arm to fix 
the humerus while the opposite hand secures the forearm at about 
its middle; the forearm is then rotated (supinated and pronated) 
while upward pressure in the axis of the radius forces the head of 
the bone up against the capitellum. Reduction is usually accom- 
panied by a soft click, after which all the functions of the joint 
are found to be normal and painless. Aften this maneuver is 
complete the elbow is tested by carrying the forearm through 
flexion, extension, supination and pronation. If the function is 
not completely restored and painless the manipulation should be 
repeated. It may be necessary to alternate extension with upward 
pressure. It will only be a few hours following reduction until 
the child is using the arm freely and without discomfort. The 
condition is not a serious one even if allowed to go unreduced, 
but proper treatment will relieve the child and obviate much 
anxiety. The displacement will not return unless the same forces 
which first produced the subluxation are again inflicted on the parts, 
and accordingly all that is necessary to prevent recurrence is to 
see that those having to do with the child are thoroughly informed 
and cautioned concerning the manner in which the injury was pro- 
duced. 

Operative Treatment. — The open method is indicated when other 
means fail to accomplish and maintain reduction for the correction 
of ancient luxations and occasionally in the treatment of compli- 
cations. A longitudinal incision is made over the head of the 



182 FRACTURES AND DISLOCATIONS 

radius, the bone exposed and reduction effected by direct manipu- 
lation. It may be possible to suture the torn orbicular ligament 
after the head has been replaced, though in some cases it may be 
difficult to recognize this structure. In any case it is proper to 
suture the structures surrounding the upper end of the bone in 
such a manner as to prevent redisplacement. When the radial 
head is much comminuted it is often better to remove the frag- 
ments, round up the end of the bone and suture the tissues about 
it. Rotation of the upper end of the bone, as evidenced by supina- 
tion and pronation, is seldom lost following these operations if the 
axis of the radial shaft remains unchanged. Moreover these cases 
usually show a surprising stability of the joint when recovery is 
complete. 

Complicating fracture of the upper end of the ulnar shaft is 
not an uncommon condition accompanying anterior luxation and 
may demand operation to maintain reduction in both fracture 
and dislocation. The dislocation is not particularly prone to recur 
but the fracture is sometimes difficult to hold in reduction because 
of the instability of the radio-humeral articulation. It is more 
often necessary to wire the fracture in the ulna than it is to operate 
on the luxation. If the ulna is approached through a posterior 
incision and the fragments secured by internal fixation it will often 
be possible to treat the luxation in the flexed position, and thus 
prevent displacement of the radial head. 

If the upper end of the bone has been allowed to remain dis- 
placed the removal of longitudinal pressure commonly results in 
an over-growth of the bone with a corresponding increase in 
length. In operating on ancient luxations, therefore, it may be 
necessary to resect the head of the bone before the shaft can be 
brought back into alignment. Old anterior luxations come to 
operation more frequently than either the outward or posterior 
types because of the loss of acute flexion in forward dislocations. 
The excellent functional results following operation on old cases, 
even when the head is resected, are often surprising. 

Malgaigne's subluxation never requires operation. 

After-Treatment. — The elbow should be fixed in the position 
least favorable to recurrence for a period of at least twenty-five to 
thirty days. In anterior luxations there is usually less tendency 
to recurrence and accordingly the period of fixation need not be 
so long. Three to four weeks will, as a rule, be ample. When frae- 



DISLOCATIONS OF HEAD OF RADIUS 183 

tiire complicates luxation union of the fragments is the chief con- 
sideration in the after-treatment and the retentive dressings should 
be removed only after one is satisfied that union is firm (usually 
four or five weeks). When fracture is present the case will require 
more careful supervision. The traumatic reaction is greater and 
the same precautions are to be observed as cited under fractures 
of the bones of the forearm. Malgaigne's luxation requires no 
after-treatment. 

Prognosis. — In the uncomplicated luxation of the head of the 
radius, where reduction has been effected, restoration of function 
should be complete. If complications exist the prognosis varies 
with the nature of the associated injury. 



CHAPTER XIII. 

FRACTURES OF THE BONES OF THE FOREARM. 

In considering fractures of the radius and ulna it will be found 
more satisfactory to describe them according to the level of the 
break rather than to take up each bone separately from end to 
end. It is well appreciated that various combinations of fractures 
may exist in the forearm regardless of the level ; thus the lower 
end of the radius and the upper end of the ulna may be broken at 
the same time, or a fracture of the neck of the radius may be ac- 
companied by a break in the lower end of either bone. It is mani- 
festly impracticable to enter into the details of these various pos- 
sible combinations of fracture, but if the student appreciates the 
nature of the breaks as described in the following pages he will 
be able to modify the treatment to meet the requirements of un- 
usual combinations of fracture as they occur. 

The order in which fractures of the bones of the forearm will be 
considered is as follows : 

Fractures of the upper end of the ulna. 
Fractures of the upper end of the radius. 
Fractures of the shafts of the radius and ulna. 
Fractures of the lower end of the ulna. 
Fractures of the lower end of the radius. 



184 



CHAPTER XIV. 

FRACTURES OF THE UPPER END OF THE ULNA. 

Surgical Anatomy. — ]\Iuch that has already been said concerning 
the anatomy of "Fractures of the Lower End of the Humerus" 
(page 120) and "Dislocations of the Elbow" (page 154) is equally 
important in fractures of the upper end of the ulna since the re- 
gion is the same. Fractures of the upper extremity of this bone 
may be of the olecranon, the coronoid or just below the latter 
process in the upper thickened portion of the shaft. Occasionally 
the nature of the break or its position is atypical. The most im- 
portant and at the same time the most common fracture occurring 
in the upper end of the ulna is of the olecranon process. This 
process is large, thick and curved, and projects upward behind 
the lower end of the humerus when the elbow is extended. Its 
upper surface is roughly quadrilateral and affords attachment to 
the tendon of the triceps. A portion of this tendon is continued 
through a heavy aponeurosis onto the posterior surface of the 
process, and thus the pull of the triceps may be exerted on the 
lower fragment in fractures of the olecranon, when the aponeu- 
rosis is not torn. The upper margin of the olecranon, anterior to 
the insertion of the triceps, affords attachment to the posterior 
bands of the lateral ligaments. These ligaments serve to keep 
the anterior surface of the process in contact with the trochlea 
when broken off from the remainder of the bone. The posterior 
surface of the olecranon is covered by a bursa and when this 
bursa is inflamed or enlarged as in " miner 's elbow ' ' the deformity 
may be marked. It does not resemble fracture but has been mis- 
taken for it. 

The interior of the olecranon is composed of a fine meshed can- 
cellous tissue, while the surface consists of compact tissue, varying 
in thickness in different regions of the process. The compact bone 
is thickest in the region corresponding to the sigmoid cavity. That 
covering the posterior surface of the process is a little heavier 
than occurs in the adjoining regions. The cancellous tissue below 

185 



186 FRACTURES AND DISLOCATIONS 

the coronoid process is quite wide meshed and not as strong as 
that found in the olecranon. About half an inch below the coro- 
noid the compact bone begins to grow thicker and rapidly in- 
creases in weight as the middle of the shaft is approached. The 
structure of the bone in the olecranon explains the inadvisability 
of using nails or screws when securing the fragments by internal 
fixation. (See Fig. 269, page 204.) 

The upper epiphysis of the ulna consists of a thin layer or scale 
of bone at the top of the olecranon which first shows ossification 
in the tenth year, and joins the shaft during the sixteenth or 
seventeenth j^ear. The fact that the triceps is attached not only 
to the upper end of the olecranon but to the posterior surface, 




Fig. 252. — Avulsion of cortical layer of compact tissue in which triceps finds inser- 
tion. 

accounts for the comparative rarity of avulsion and separation of 
this epiphysis. The line of the epiphyseal cartilage has been 
mistaken for fracture. 

As previously stated the powerful triceps is inserted into the 
olecranon process of the ulna, but its antagonist the biceps is at- 
tached to the bicipital tuberosity of the radius. Thus it will be 
noted that the heavy extensor and flexor muscles of the forearm 
are able to balance each other only because the two bones of the 
forearm are firmly bound together. Fracture of the olecranon, 
or fracture below the level of the sigmoid cavity with separation 
of the fragments, destroys the balance between the biceps and 
triceps. The brachialis anticus attached to the coronoid process 
is a flexor, and in fractures below the process this muscle tends to 



FRACTURES OF UPPER END OF ULNA 



187 



counteract the pull of the triceps, but its relative weakness results 
in the upper fragment being carried into extension if the aponeu- 
roses have been torn sufftciently to allow deformity. 

The mechanism of fracture of the olecranon has been the subject 
of considerable discussion ; suffice it to say that most fractures of 
the olecranon are probably the result of a combination of direct 
violence and muscular action. Thus when a person falls heavily 




Fig. 253. — Fracture of olecranon. Elbow extended. 




Fig. 254. — Same case, 
tween fragments. 



Elbow slightly flexed, showing increase of distance be- 



on the outstretched hand the triceps is firmly fixed in anticipation 
of the blow. If the force is great the hand is forced toward the 
body and a heavy strain is sustained by the process. Under 
these circumstances the elbow usually strikes the ground as flexion 
increases. Thus there is a combination of direct and indirect 
violence, and it is difficult to distinguish which of the two is the 
more important etiologic element. Cases are known in which the 



188 FRACTURES AND DISLOCATIONS 

injury seems to have been produced entirely by muscular action, 
while in other instances direct violence alone has undoubtedly 
been responsible for the fracture. Fracture of the olecranon 
produced experimentally by direct violence has been of a different 
type than that commonly seen clinically. The amount of displace- 
ment of the upper fragment is usually greatest in cases resulting 
from muscular action though great separation is sometimes seen 
where the injury has been caused by a blow on the elbow. The 
displacement depends, to a great extent, on the tearing of the 
aponeurosis on the posterior surface of the process. The line of 
fracture is usually transverse and most often occurs at the bottom 
of the sigmoid fossa where the process is thinnest. The break 
usually enters the joint and when compound the elbow is exposed 
to infection. The deformity is usually characteristic ; the upper 
fragment follows the curved surface of the trochlea so that the 
space left between the broken surfaces is the shape of a truncated 
wedge, with the narrow end of the wedge transversely situated 
against the trochlea while the base stands backward and down- 
ward. 

Fracture of the coronoid is an extremely rare condition except 
as a complication of backward dislocation of the elbow (q. v.). 

In fractures below the coronoid it is not uncommon to find the 
head of the radius luxated forward, which condition has been 
described under "Dislocations of the Head of the Radius." 

Symptoms. — Immediately following the injury the patient finds 
that he is unable to actively extend the forearm, though motion 
may be accomplished passively or by the action of gravity. IMotion 
is painful and the patient usually supports the forearm in a semi- 
flexed position with the uninjured member. When separation is 
present the deformity is characteristic if seen early before the 
elbow is much swollen. The point of the elbow is gone ; the pos- 
terior aspect of the joint has a rounded effect instead of its normal 
angularity, and in some cases the position of the displaced frag- 
ment may be determined by inspection alone. Swelling of the 
parts comes on rapidly in most cases, and after it is well established 
there is nothing characteristic in the outline to differentiate the 
condition from the swollen states seen following other injuries 
about the elbow. Palpation, however, readily clears up the diag- 
nosis as sho^TL in Fig. 256. In many cases there is separation of 
the fragments when the forearm is flexed but none with the elbow 



FRACTURES OF UPPER END OF ULNA 



189 



in extension, and accordingly the evidences of separation will vary 
with the degree of flexion at the elbow. Lateral mobility may be 
noted, especially abnormal abduction of the forearm. The dis- 




Fis. 255. — Fracture of the olecranon about one week following the accident. The 
characteristic deformity seen in recent cases is here obscured by the intense swelling. 
Note ecchymosis. Diagnosis cannot be made by inspection alone. 




Fig. 256. — Same case. Diagnosis established by palpation. Thumb rests on top 
of olecranon. The index finger occupies the depression between the fragments. The 
middle finger rests on the upper end of the lower fragment. Note how the index finger 
sinks in between the fragments. 



tance between the fragments is variable, the greatest separation 
being seen in old cases with fibrous union, in which the bond has 
stretched with use. 



190 FRACTURES AND DISLOCATIONS 

It is not uncommon to see fracture of the olecranon with little 
or no separation of the fragments, and under these circumstances 
some of the characteristic symptoms will be wanting. The power 
of active extension w411 be slightly if at all disturbed though the 
action will be painful. Lateral mobility of the process and crepitus 
are usually present though they are often not well marked when 
the fracture has been accompanied by only slight tearing of the 
aponeurosis. "With separation of the fragments crepitus can only 
be elicited when the fragments are approximated and the broken 
surfaces rubbed together. Ecchymosis is almost invariably seen 
within twenty-four hours of the accident. 

In compound cases the wound is usually situated on the pos- 
terior aspect of the elbow^ and it may be possible to see the line 
of fracture and the displaced fragment. 

Fractures of the coronoid and fractures of the ulna just below 
this process have been considered under "Dislocations of the 
Elbow." Isolated fracture of the ulna just below the coronoid is 
an extremely rare accident and is usualh^ the result of direct 
violence. It will be accompanied by abnormal mobility, crepitus, 
loss of function, etc. 

Diagnosis. — If the case is seen early there will usually be little 
difficulty in recognizing fracture of the olecranon if the symptoms 
just described are sought. Fracture without displacement may 
escape recognition if the parts are not thoroughly and carefully 
examined. The posterior border of the ulna is subcutaneous 
throughout and by tracing it upward from below the position of 
the fracture and the displaced fragment can as a rule be felt. 
Even where there is no displacement it is often possible to detect 
some loss of alignment on the posterior border of the olecranon 
and by grasping the process laterally, motion and crepitus may be 
elicited. In establishing a diagnosis of fracture of the olecranon 
the elbow should be examined systematically as already described 
under ''Fractures of the Lower End of the Humerus" (page 137) 
and in "Dislocations of the Elbow" (page 163). 

The condition must be differentiated especially from fractures 
of the lower end of the humerus and backward luxation of the 
elbow. 

Treatment. — The methods of treatment employed will depend 
entirely on the conditions present. Where there is no separation 
the right angle splint will meet the requirements of the case, in 



FRACTURES OF UPPER END OF ULNA 



191 



7 



/ 



addition diagonal strips of zinc oxide adhesive should be so placed 
as to bind down the olecranon and relieve the npper fragment 
of the displacing action of the triceps. "When displacement exists 
the time-honored straight splint is indicated. The elbow should 
not be treated in extreme extension because in the 
first place, the position becomes intolerable to the 
patient in a short time and secondly, the tip of the 
olecranon in this attitude is not sufficiently promi- 
nent to afford the proper purchase for the straps 
of adhesive used in binding the fragment in a po- 
sition of reduction. A straight board may be used 
a little broader than the arm, and wdth sufficient 
padding at the elbow to allow a few degrees of 
flexion. The splint should be secured by three 
strips of adhesive plaster encircling the member; 
one at either extremity of the splint and the third 
just above the elbow. It should extend from a point 
just below the axillary fold to the wrist; there is 
little to be gained by extending the splint downward 
to include the hand, the patient being much more 
comfortable when some action at the wrist and 
fingers is allowed. The straight splint is very cum- 
bersome at best and is not a desirable method of 
fixation when other means can be made to ac- 
complish the purpose- A neat and satisfactory 
method of making a straight splint is to use quarter- 
inch iron wire ; this is bent to fit the arm in a posi- 
tion short of complete extension and bandaged the 
same as the Cabot posterior wire splint employed 
in the treatment of fractures of the leg. A slight 
bend is made at the elbow to allow a little flexion 
of the forearm. When the fracture is compound 
it should be treated according to the principles laid 
down under "The Treatment of Compound Frac- 
tures and Luxations," on page 789. 

Operative Treatment. — Of late years operation has, to a great 
extent, supplanted the ordinary methods, and there has been a 
great deal of discussion on the subject, pro and con. There is 
a large proportion of cases which make excellent functional re- 
coveries without operation, and it is unwise to resort to the open 



Fig. 257. — nius- 
trates the use of the 
straight splint in the 
non-operative treat- 
ment of fracture 
of the olecranon. 
Note the diagonal 
strap of adhesive 
which hinds the up- 
per fragment in po- 
sition. Slight flex- 
ion of the elbow 
affords a better hold 
for this strip of ad- 
hesive. 



192 FRACTURES AND DISLOCATIONS 

method in all cases. When the fracture is not compound and there 
is no displacement of the fragments operative intervention can ac- 
complish nothing, but on the other hand when there is displacement 
which cannot be perfectly corrected or when the fracture is com- 
pound there is no method that will be as successful as operation. 
Between these two types is a third class in which the best mode of 
procedure is not so evident. AA^hen the condition is not compound 
and there is only moderate separation, which can be fairly well 
corrected by other means, the question then arises: does the patient 
prefer to submit to an operation for the sake of a more rapid 
and perfect result, or would he rather endure a more protracted 
convalescence and assume the responsibility of an imperfect func- 
tional result which may go with fibrous union? In these border- 
land cases the situation should be laid before the patient and he 
should be the one to assume the responsibility if operation is 
rejected. Fibrous union, when the fragments are close and the 
mass of fibrous tissue heavj^, is usually accompanied by excellent 
results, and cases in which these conditions obtain are a strong 
argument against operation. It should be remembered, however, 
that it is impossible to foretell just how strong fibrous union 
will be in a given case. The age, condition and occupation of 
the patient are factors which must be taken into consideration 
in advising the proper method of procedure. Limitation of full 
extension is directly proportionate to the separation of the frag- 
ments. If the broken olecranon is displaced upward it becomes 
seated in the olecranon fossa before the elbow is fulty extended, 
and thus motion is limited. Full extension, therefore, cannot be 
expected unless the fragaients are in accurate apposition. It might 
be stated as a rule that young or middle aged persons, especially 
of the working class, should be operated when the fragments can- 
not be approximated by ordinary methods. By the open method 
convalescence is shortened and the function of the joint is more 
completely restored. 

The process is exposed through a longitudinal incision external 
to the posterior surface of the olecranon. The scar in this position 
is not exposed to pressure when the patient rests the elbow on a 
table or other convenient object. After the fragments are ex- 
posed two transverse holes are drilled one above and the other 
below the plane of the fracture. All loose tissues are then cleared 
away between the two fractured surfaces and the upper fragment 



FRACTURES OF UPPER END OF ULNA 



193 



brought down and accurately fitted into the serrations of the 
lower one. Suture material is then passed through the holes and 
the fragments solidly secured in position Instead of this method 
a heavy mattress suture may be placed, as shown in Fig. 259. 




Fig. 258. — Fracture of olecranon showing separation of fragments in spite of 
dressings tending to correct the deformity. 




Fig. 259. — Same case showing accurate reduction following operation in which mat- 
tress suture of silver wire was used to maintain reduction. 



There has been considerable discussion concerning the best type 
of suture, and of late absorbable materials such as chromic catgut 
and kangaroo tendon have been frequently employed. The author 
much prefers wire to absorbable material, since the latter is more or 
less likely to soften and stretch before the callus is firm enough to 



194 FRACTURES AND DISLOCATIONS 

withstand the unavoidable tension of the triceps, and when it 
does there will be at least some slight separation of the fragments. 
Silver wire has no stretch in it and will hold the fragments in 
position as long as may be necessary, and in addition will permit 
of early and repeated passive motion with greater safety. (See 
''Operative Treatment of Fractures," page 758.) In compound 
cases the wound should be irrigated with a few gallons of physi- 
ologic sterile salt solution, and the edges of the wound trimmed 
of devitalized tissue as described in "The Treatment of Compound 
Fractures and Luxations," on page 789. Internal fixation of the 
fragments should not be performed at the initial operation in com- 
pound cases though it may be possible to retain the fragments in 
position by suturing the fascia covering the posterior surface of the 
process, in closing the wound. A secondary operation may be done 
after the wound (rendering the condition compound), has healed 
and the danger of infection has passed. 

Following a firm internal fixation of the fragments the upper 
extremity may be immobilized with an internal right angle 
splint. 

Old cases of fracture of the olecranon sometimes require opera- 
tion because of separation of the fragments and loss of function. 
The difficulty is purely mechanical and calls for mechanical cor- 
rection. The joint is approached through a longitudinal incision 
as just described ; the fibrous tissue is excised and the upper frag- 
ment brought down into apposition with the lower. The ends of 
the fragments must be freshened before being sutured together, 
but as little bony tissue should be removed as possible. In cases 
of long standing it may be necessary to lengthen the tendon of the 
triceps so that the elbow may be fully flexed after the fragments 
have been sutured together. 

In rare instances fracture of the coronoid may require operation 
if the fragment is large and much displaced, and if immobilization 
of the elbow in the flexed position does not effect reduction. It 
will usually be possible to retain the fragment by suture of the soft 
parts since there is little displacing action if the elbow is subse- 
quently fixed and treated in the flexed position. In making the 
incision to expose this process the greatest care should be exercised 
to avoid injury to the brachial artery and median nerve as they 
pass across the bend of the elbow. 

Fracture of the upper end of the ulna below the coronoid is 



FRACTURES OF UPPER END OF ULNA 



195 



especially rare and seldom requires operation except when accom- 
panied by anterior dislocation of the elbow. The treatment of this 
condition has been considered under ''Dislocations of the Elbow," 
page 170. 

After-Treatment. — If non-operative methods have been followed 
and the straight splint used the arm should be inspected daily for 
the first two weeks to see that there is no undue constriction of the 
parts and that the straps binding the olecranon down are accom- 
plishing the purpose. The same precautions are to be observed if 
the right angle splint is employed. If the soft tissues have suffered 
much injury it is usually advisable to delay reduction of the frac- 
ture until the traumatic reaction has subsided. Durinp^ this time 




Fig. 260. — Illustrates method of employing passive motion in the after-treatment of 
fractures of the olecranon. The thumb forces the olecranon to follow the shaft of the 
ulna as the elbow is being flexed. 

it is best to treat the patient in bed with the arm immobilized on an 
internal right angle splint. The intermittent use of the ice cap 
will aid materially in controlling the reaction. The swelling will, as 
a rule, have subsided sufficiently at the end of a week or ten days 
to permit of reduction and immobilization, or operation if thought 
best. Massage is of great service after the swelling has passed off 
but is capable of doing harm during the active inflammatory reac- 
tion. Passive motion should be instituted at the end of two weeks 
but should be guarded, gentle and painless at first, and the arm 
should be carried through only a few degrees of flexion. At the 
end of three weeks much freer motion is permissible in manipu- 
lating the elbow. The greatest care, however, should be exercised 



196 FRACTURES AND DISLOCATIONS 

at all times not to cause separation of the fragments during passive 
motion, especially if they have not been wired. In moving the 
joint the thumb should be placed above the process as shown in 
Fig. 260 and downward pressure exerted on the end of the process 
to force the fragment to follow the movements of the shaft during 
flexion of the elbow. Early passive motion is essential to the pre- 
vention of adhesions within the joint, yet if not properly guarded 
it may do more harm than good. Union of the fragments usually 
takes place at the end of three or four weeks, but the callus is not 
strong enough to withstand much strain at this time. At the end 
of four or five weeks immobilization may be discontinued. At the 
end of two and a half to three months recovery is complete though 
the patient should be cautioned not to use the arm in any work 
requiring violent extension, within six months from the time of the 
injury. 

Prognosis. — The prognosis depends on the severity of the injury 
and the efficiency of the treatment. In the uncomplicated case, 
with little or no separation of the fragments, perfect restoration 
of function should follow non-operative treatment. Recovery with 
fibrous union may or may not be accompanied by a useful elbow. 
If the fibrous tissue is short and thick, function will, as a rule, be 
good. If it is thin and stretches with use the power of the triceps 
will be lessened or lost and extension incomplete. Severe traumatic 
reaction and prolonged immobilization of the elbow render the 
prognosis worse, since they are productive of joint adhesions. Ap- 
proximation of the fragments by internal fixation and earh^ pas- 
sive motion are usually followed by complete restoration of 
function. It is of course possible to have perfect function with 
fibrous union, while on the other hand loss of function may be 
pronounced even when the anatomical result is perfect. The larg- 
est percentage of perfect results, however, will be found in the 
cases showing the most perfect reduction, other things being equal. 
In compound cases the prognosis depends largely on whether or 
not the joint becomes infected. (See ''Treatment of Compound 
Fractures and Luxations," page 789.) 



CHAPTER XV. 

FRACTURES OF THE UPPER END OF THE RADIUS. 

Surgical Anatomy. — The sections on "Surgical Anatomy" under 
the headings of ''Fractures of the Lower End of the Humerus," 
''Dislocations of the Elbow" and "Dislocations of the Head of the 
Radius" apply in a large measure in fractures of the upper end 
of the radius. The head of the bone is surrounded by the orbicu- 
lar ligament, except where the latter comes in contact with the 
lesser sigmoid cavity of the ulna. The supinator brevis is attached 




Fig. 262. 



Fig. 261. — Fracture of head and neck of radius. 
Fig. 262. — Comminuted fracture of head of radius. 



to the shaft and extends upward onto and almost completely sur- 
rounds the neck of the bone. The biceps is attached to the pos- 
terior half of the tuberosity and acts as a supinator of the forearm 
as well as producing flexion. A bursa is interposed between the 
tendon of this muscle and the anterior half of the tuberosity. The 
interior of the head of the radius is composed of a fine meshed 
cancellous tissue which is covered by a layer of compact bone. 
The surface compact tissue is heaviest on the top of the head. The 
circumference of the head, coming in contact with the orbicular 

197 



198 



FRACTURES AND DISLOCATIONS 



ligament, is covered by only a very thin layer of compact bone. 
That found on the surface of the neck is a little heavier. The 
tuberosity is not a heavy, solid prominence of compact tissue but 
is composed only of a thick crust of compact bone, the interior 
being made up of a wide meshed cancellous tissue. 

The upper epiphysis of the radius consists of a scale of bone 
corresponding to the superior articular surface. When viewed 
laterally under the X-ray it appears as a line, throwing much the 
same shadow as would a coin seen on edge. This epiphysis begins 




Fig. 263. — Fracture of head and neck of radius. 



to ossify in the fifth year, and joins the shaft during the seven- 
teenth or eighteenth year. 

Fracture of the upper end of the radius is rare. The head may 
be broken as a complication of luxations, by violence transmitted 
in the long axis of the shaft (such as sustained in falls on the 
hand) and by direct trauma. The fracture may consist of a small 
fragment detached from the articular surface or the entire head 
may be extensively comminuted. Impaction of the neck into the 
head is not an uncommon type of injury. When this occurs im- 
paction is usually greater on one side of the bone than on the 
other, so the head is no longer ''true" when the shaft is rotated. 



FRACTURES OF UPPER END OF RADIUS 



199 



Fractures of the neck are iisiially transverse or nearly so. A verti- 
cal fracture may exist passing throngli both head and neck. 

Fractures of the upper end of the radius are, as a rule, accom- 
panied by only slight deformity, if any, and almost invariably 




Fig. 264. — Fracture of head of radius. 




Fig. 26.5. — Fracture of head uf i-; 
Head "off center." 



•ted into head. 



exist as complications of dislocations of the elbow or radial head 
alone, or of fracture of the lower end of the humerus or of the 
ulna. As an isolated injury they are unusual though by no means 
as rare as supposed prior to the advent of the X-ray. 

Symptoms. — Fracture of the head of the radius alone is often 
productive of very few symptoms, and if not thoroughly examined 
the condition may be overlooked and treated as a sprain. Local 
pain and swelling are present over the head of the bone. The 
swelling may extend halfway down the outer aspect of the forearm 



200 FRACTURES AND DISLOCATIONS 

and local spasm of the muscles in this region is almost invariably 
present. Supination and pronation are usually possible but this 
rotary action of the forearm may be restricted through spasm and 
pain, or by the head of the bone being "off center." If a frag- 
ment becomes displaced into the joint it may block either flexion 
or extension of the elbow. 

It may be possible to detect crepitus by direct manipulation and 
in some cases a fragment may be felt and moved. Crepitus is most 
commonly elicited by supinating and pronating the forearm while 
the fingers of the opposite hand palpate the head. The head of 
the bone may or may not rotate with the shaft during this manipu- 
lation, depending on whether or not the fractured surfaces are 
firmly engaged. It is impossible to detect crepitus in impacted 
cases. Failure of the head to rotate with the shaft is conclusive 
when present, but it is not at all uncommon to find the head ro- 
tating with the shaft in the presence of fracture of the head or 
neck. When the fractured surfaces are not engaged the biceps 
may pull the upper end of the lower fragment forward and the 
resulting change in the axis of the radial side of the forearm may 
be apparent. This forward displacement by the biceps usually hin- 
ders flexion until the deformity is corrected. 

Diagnosis. — The diagnosis of fracture of the upper end of the 
radius may be very easy or quite difficult, depending on the symp- 
toms. If the parts are carefully examined it will usually be pos- 
sible to determine the nature of the injury by the symptoms just 
described, but in some cases (especially well muscled persons and 
instances in which the swelling is pronounced) a Rontgenogram 
may be necessary to arrive at a diagnosis. Behind the external 
condyle of the humerus and head of the radius, and internal to 
the extensor tendons arising from the epicondyle, is a depression 
or dimple which affords ready access in palpating these bony parts. 
A slight transverse depression between the capitellum and radial 
head may be felt and the radius should be distinguished from the 
humerus. The surgeon should not make the mistake of palpating 
the external condyle to determine rotation of the radial head. 
Such a mistake w^ould not seem probable yet the author has seen 
it made more than once. The X-ray should be used if there is the 
least doubt as to the nature of the condition. 

Treatment. — The management of these cases depends on the 
nature of the fracture, the displacement of the fragments and the 



FRACTURES OF UPPER END OF RADIUS 



201 



association of other lesions. When the fracture is confined to 
the head, the orbicular ligament, if not ruptured, will usually pre- 
vent displacement of the main fragments, though a portion of the 
head may escape into the joint and require removal. As a rule, 
however, fracture of the upper end of the radius calls for little 
aside from immobilization of the forearm, which is well accom- 
plished by an internal right angle splint. If the head is badly 
comminuted it may be advisable to remove the fragments, round 
up the end of the shaft and secure it in place by suturing the 




Figs. 266 and 267. — Loss of carrying angle and gun-stock deformity the result of 
fracture of both bones helow the elbow. Palpation in this case shows the liumeral 
condyles and olecranon to be in normal relation. Loss of carrying angle and gun- 
stock deformity are usually the result of fracture of the lower end of the humerus. 

orbicular ligament and other adjacent fibrous tissue over it. When 
obstruction to flexion or extension is caused by a detached frag- 
ment of the head it should be. removed. When the fracture is 
below the head, and the shaft is displaced forward by the action 
of the biceps, the splint should be so padded that pressure will be 
made in a backward direction on the upper end of the lower frag- 
ment. The use of pads and the acutely flexed position should never 
be employed at the same time. The use of padding in the bend 
of the elbow with the forearm in acute flexion, may give rise to 



202 FRACTURES AND DISLOCATIONS 

serious disturbances of the circulation and in the function of the 
median nerve. When the fracture is below the orbicular ligament 
acute flexion will sometimes afford better reduction than the use 
of direct pressure and the right angle splint. 

Operative Treatment. — Operation may be indicated for the 
removal of a loose fragment in the joint or to apply internal fixa- 
tion to a fracture of the neck when other means fail to maintain 
reduction. The open method, however, is seldom called for in 
recent cases. When a loose fragment requires removal the incision 
will be made according to the position of the fragment. For other 
conditions of the upper end of the radius, requiring operation the 
posterior longitudinal incision will be found as satisfactory as any. 
The posterior aspect of the external condyle is a landmark from 
which the incision is begun and carried directly downward from 
two to three inches; after the skin incision is made the muscles 
are separated and the upper end of the radius exposed. In the 
presence of much comminution the head is to be excised, the end 
of the shaft rounded up and sutured in place. If the fracture is 
somewhat below the head it may be possible to so place a loop of 
wire that the lower fragment will be bound to the upper, thus 
preventing the forward displacement due to the pull of the biceps. 
The action of the biceps may be somewhat further relaxed by put- 
ting the arm up in greater flexion than the right angle. There is 
little that can be done with fracture of the head aside from exci- 
sion, but unless the comminution is great it is best to wait and 
determine how much restriction of motion wall be present when 
recovery is complete. If the loss of function is then pronounced 
a secondary operation may be performed and the head removed. 
It is surprising what good results often follow complete excision of 
the head. Fractures above the lower border of the orbicular liga- 
ment seldom unite, regardless of the treatment employed, so there 
is little use in attempting anything in the "way of operative pro- 
cedure aside from excision in fractures confined to the head. 

After-Treatment.— The afte-r-treatment of fractures of the upper 
end of the radius, like other fractures about the elbow, requires 
close attention to avoid constriction when swelling sets in, and as 
the arm decreases in size during the subsidence of this swelling 
the dressings should be tightened daily to secure proper support 
and immobilization. In children union will be present at the end 
of two and a half weeks, but is not firm enough at this time to 



FRACTURES OF UPPER END OF RADIUS 203 

permit of removal of all dressings; the member should be pro- 
tected and supported for another ten to fifteen days before all 
splints are removed, especially if the child is active and not easily 
controlled. In adults the parts should be immobilized for a period 
varying- from three to five weeks according to the age of the 
patient. If the fracture is confined to the head union cannot be 
expected, regardless of the period of immobilization, and the most 
important element in the after-treatment is then the early insti- 
tution of passive motion to preserve the rotary action of the fore- 
arm. Passive supination and pronation should be begun as early 
as the end of the first week or ten days unless the traumatic reaction 
persists. When the fracture is of the neck passive motion should 
be delayed until union is firm enough to withstand manipulation. 
Prognosis. — The outlook depends on the nature of the fracture 
and the treatment followed. In extensive comminution of the 
head there is likely to be pronounced loss of supination and pro- 
nation of the forearm although the rotary action of the forearm 
is usually restored with operation and excision. Perfect function 
shonUl follow fracture of the neck if the fragments unite in ap- 
proximation ; if there is deformity following recovery the rotary 
action of the forearm may be seriously impaired. 



CHAPTEE XYI. 

FRACTURES OF THE RADIAL AND ULNAR SHAFTS. 

Surgical Anatomy.— The shafts of the bones of the forearm may 
be broken together, or either bone may be broken separately. It 
is more common to see both bones broken than to find a fracture 
of either bone as an isolated injury. Fracture of the radius alone 
is often the result of indirect violence ; the lower end of the radius 




Fig. 268. — Section of radius showing disposition of compact and cancellous tissue. 




Fig. 269. — Section of ulna showi'ng disposition of compact and cancellous tissue. 
O., Olecranon; C, Coronoid. 

supports the carpus and violence sustained by the hand is trans- 
mitted to this bone rather than the ulna. Fracture of the shaft 
of the ulna is usually the result of direct violence ; the posterior 
border is subcutaneous throughout and is particularly exposed to 
injury in falls on the back of the forearm and in warding blows 

204 



FRACTURES OF RADIAL AND ULNAR SHAFTS 205 

from the head. When both bones are broken the cause may be 
either direct or indirect violence. Fracture of the bones of the 
forearm is a particularly common accident in childhood. When 
the shaft of either bone is broken alone the deformity is, as a rule, 
not pronounced since the opposite shaft acts as a splint in prevent- 
ing displacement. 

The various deformities accompanying fractures of the radial 
and ulnar shafts depend on the nature and direction of the causa- 
tive trauma and the different muscles attached to the bones. In 
speaking of the deformities due to muscular action in different 
regions of the forearm it will be understood that they obtain only 
when the serrated fractured surfaces are not so engaged as to pre- 
vent displacement. Fracture of the radial shaft, below the tuber- 
osity and above the insertion of the pronator radii teres, is likely 
to be accompanied by supination of the upper fragment and pro- 
nation of the lower. The biceps and supinator brevis produce 
supination of the upper fragment, and the first named muscle will 
also tend to displace the lower end forward. The lower fragment 
will occupy a position of pronation due to the action of the pro- 
nator radii teres and the pronator quadratus, and the upper end 
of the lower fragment will usually be displaced toward the ulnar 
shaft through the action of these two muscles. When the fracture 
is below the insertion of the pronator radii teres both fractured 
ends will be displaced toward the radius by the pull of these two 
pronators. In fractures of the shaft of the ulna the upper end 
of the lower fragment may be displaced toward the radius by the 
action of the pronator quadratus; the nearer the fracture is situ- 
ated to the upper border of this muscle the more pronounced the 
action. 

The relation of the bones during supination and pronation is of 
importance in treating fractures of the forearm. In supination 
the interosseous membrane is taut and the two bones in the same 
plane. As the forearm is carried into pronation the lower end of 
the radius describes an arc about the lower end of the ulna, and 
when pronation is complete the radial shaft crosses the shaft of 
the ulna obliquely. In complete pronation the shafts of the two 
bones are nearer than in any other position. The obliquity of the 
fibres of the interosseous membrane is such that with upward 
longitudinal stress on the radius a portion of the strain is imparted 
to the ulna. The oblique ligament is composed of fibres passing 



206 FRACTURES AND DISLOCATIONS 

in the opposite direction and tends to prevent the radius being: 
pulled away from the humerus. The shafts of both bones are 
composed of heav}" tubes of compact tissue, and the fractures seen 
in this region are those common to the shafts of other long bones. 
They may be transverse, oblique, spiral, comminuted, multiple, 
green-stick, subperiosteal, etc. Divergence of either the upper or 
lower pair of fragments occurs only with rupture of the inter- 
osseous membrane and is rare. In unusual cases the ends of all 
four fragments may be close together and embraced by one callus. 
In other instances angular deformity of the fragments of one bone 
toward the opposite shaft may be accompanied by a large callus 
which interferes with the rotary action of the' forearm. When 
both bones are fractured the break in the ulna is usuallv at a sli^htlv 




Fig. 270. — Fracture of both bones of the forearm the result of direct violence. Hand 
displaced dorsally and slightly to the radial side. Fracture of ulua transverse and de- 
formity pui-ely angular. Fracture of radius is slightly oblique so that there is an ele- 
ment of overriding as well as angularity in the displacement of this bone. The slight 
overriding of the radial fragments causes the hand to be displaced a little to the radial 
side as well as backward. Arrow points to wound produced by lower end of upper 
fragment of radius penetrating the skin. Angular deformity corrected at once. Radius 
could not be perfectly reduced and persisted in slipping out of place. Operation about 
one week following injury ; radius secured in reduction by circular Avire, which is bad 
practice in compound cases before the wound has healed. (See "Operative Treatment 
of Compound Fractures and Luxations.") Ultimate recovery perfect. 

higher level. In rare instances the fractures may be situated at 
opposite ends of the shafts. Muscular action is known to have pro- 
duced fracture of the bones of the forearm, but is extremely rare. 
Symptoms. — The symptoms accompanying fractures of the bones 
of the forearm vary with the region of the fractures, the age of 
the patient, and whether or not both bones are broken. In frac- 
tures of the radial shaft the deformity is usually not pronounced 
and may be quite difficult to recognize. If one or both fragments 
are displaced toward the ulna the radial side of the forearm mav 



FRACTURES OF RADIAL AND ULNAR SHAFTS 



207 




Fig. 271. — Another view of same case showing dorsal surface of forearm. Note 
the transverse groove indicated by the arrow. This groove indicates to some extent the 
relative levels of the two fractures. These photographs were taken immediately follow- 
ing the accident and just prior to reduction. 




Fig. 272. — Antero-posterior view of fracture of radius and ulna after reduction has 
been attempted. 



m 





Fig. 273. — Lateral view of same case showing' deformity in radial fracture. Tlie 
fracture in the radius is slightly oblique and persists in slipping out of position after 
reduction. On this account operation was performed and reduction secured by a cir- 
cular wire. 



208 



FRACTURES AND DISLOCATIONS 




Fig. 274. — Antero-posterior vie"w of same ease :-ome weeks after operation. Circu- 
lar wire Avas used and infection followed. The case was compound from the first. The 
placing of foreign materials, especially of the non-absorbable type, is to be condemned in 
operating on compound fractures. Some absorption of bone has taken place under the 
wire, and as a result slight recurrence of deformity. Wire removed — ^perfect recovery 
followed. 




Fig. 275. — Lateral view of same case. 




Fig. 276. — Fracture of both bones of the forearm usual backward dis- 

placement of the hand. Photograph about one and a halt hours following the accident. 
Angular deformity pronounced but there is no overriding of the fragments. 



FRACTURES OF RADIAL AND ULNAR SHAFTS 



209 



show an abnormal concavity as illustrated in Fig. 287. In any 
case there will be pain in the region of the fracture, tenderness on 
pressure and manipulation, swelling and more or less complete loss 
of function. If the fracture is in the lower third of the radius 
and the upper end of the lower fragment displaced toward 




Fig. 277. 




Figs. 277 and 278. — Fracture of both bones of the forearm with the usual deform- 
ity. Fractures at about same level. Pictures taken a few minutes following the acci- 
dent. 



the ulna, the radial styloid will be correspondingly raised and the 
lower articular surface changed in position. Overriding of the 
fragments and shortening, however, will be absent unless the head 
of the ulna is luxated or the ulnar shaft fractured. During supi- 
nation and pronation of the forearm the radial head will, in most 



210 



FRACTURES AND DISLOCATIONS 



cases, fail to follow the rotation of the shaft. Crepitus can, as a 
rule, be elicited if the fragments are grasped above and below the 
seat of the fracture and manipulated. If the forearm be placed in 
supination and firmly held in this position, while lateral pressure 
is exerted on the shafts of the radius and ulna by the thumb and 




\ dLl^ 



Fig. 279. — Same case showing reduction of deformity. Arrow 1 indicates the di- 
rection of pressure made by the surgeon's right hand. Arrow 2 indicates the course to 
1 :e taken by the distal fragment during reduction. Arrow 3 traction made on the lower 
fragment while it is being brought back into position. 




Fig. 280. — Shows ventral view of same case. Ventral prominence is evident but 
it will be noted that there is no displacement of the hand to either radial or ulnar 
sides. 

forefinger of the opposite hand, the normal lateral spring of the 
radial shaft will be found wanting. In children the fracture may 
be of the green-stick or subperiosteal type and accordingly crepi- 
tus and mobility will be absent. The shaft, however, usually shows 
more or less bowing in a given direction and the region of fracture 



FRACTURES OF RADIAL AND ULNAR SHAFTS 



211 



will be swollen, tender and painful. Lateral pressure on the radial 
shaft will usually show that the normal lateral spring of the shaft is 
increased and will produce pain at the seat of fracture rather than 
at the point of pressure. 

Fracture of the ulnar shaft alone is productive of symptoms 
similar to isolated fiaeture of the radial shaft except that the 




Fig. 281. 



Fig. 232. 



Figs. 281 and 282. — Lateral and antero-posterior views of case shown in Figs. 277, 
278, 279 and 280, after reduction. 



swelling, pain, tenderness, etc., are situated on the inner side of 
the forearm rather than on the radial side. Displacement is rarely 
pronounced as long as the radius remains intact. The posterior 
border of the ulnar shaft is subcutaneous throughout and unless 
the swelling is extreme it will be possible to determine the position 
of the fracture by palpation. The lower fragment is often displaced 
toward the radius. Shortening does not take place because the 
radius acts as a splint and maintains the length of the forearm. 
Use of the forearm is painful and lateral pressure on the shaft 
excites pain at the seat of fracture and not at the point of pressure. 



212 



FRACTURES AND DISLOCATIONS 




Figs. 283 and 284. — Same case as shown in Figs. 278 and 279 after reduction has 
been accomplished and splints appUed. It will be noted that the posterior splint may 
be removed for examination of the forearm without disturbing the iixation of the fore"- 
arm which is still firmly bound to anterior splint. Yucca board has been used in mak- 
ing these splints and serves the purpose admirably but should not be used unless one is 
experienced in the treatment of these cases and the forearm is closely watched for 
symptoms of strangulation. (See text.) 




Fig. 286. 
Figs. 285 and 286. — Same case at the time the splints were removed. 



FRACTURES OF RADIAL AND ULNAR SHAFTS 



213 




Fig. 2&3. 

Figs. 287 and 288. — Slightly oblique fracture of radius about three inches above 
wrist. Lower fragment displaced toward iilna. Note the increased curve in the radial 
side of forearm and the slight displacement of the hand to the radial side. (Compare 
with Figs. 290 and 291.) Reduction difficult as lower fragment persisted in slipping 
out of place. Operation performed after two attempts at reduction. Fragments wired. 
Recovery perfect. (See X-rays shown in Figs. 292 to 297.) 




Figs. 289 and 290. — Two views of the opposite arm taken for comparison. Note 
the normal curve on the radial surface of the forearm as compared with that seen in 
Figs. 288 and 289. 



214 



FRACTURES AND DISLOCATIONS 




Fl'j;'- I'ln ;:il(l -J't-J. .\llTcrn-l)nsti'V 

■ecurreiiee uf deI'o^lnit^■ after rt'cUicti'>n. 



il Yie\\s (if fracture of radius with 
us .slioAYu in Figs. 237 and 288. 




Figs. 293 and 294. — Shows same case after a second redtiction and recurrence of 
deformity. 



FRACTURES OF RADIAL AND ULNAR SHAFTS 215 

The heavy aponeurosis attached to the posterior border tends to 
prevent lateral displacement. 




Figs. 295 and 296. — Same case after operation showing correction of deformity and 
securing of fragments in position by means of a loop of silver wire. 




Fig. 297. — Fracture of hoth bones of the iiKht forearm in a child two and a half 
years of age. The deformity in this case is unusual in that the forearm is bowed back- 
ward. Photograph taken before reduction and about one hour following accident. 

When both hones are broken the deformity is usually pronounced 
and may be of either the overriding or angular type. The bones 
of the forearm may be displaced in any direction but the common 



216 



FRACTURES AND DISLOCATIONS 



deformity consists in a backward bending of the forearm; — the 
dorsal surface of the forearm forms an obtuse angle while the 
ventral surface forms the salient angle. A much less common dis- 




XL 



Fiff. 298. 



Fig. 299. 

Figs. 298 and 299. — Fracture of both bones of the forearm seen from radial and 

ulnar sides. The fractures are so low that the condition is likely to be confounded with 

Colles' fracture. It will be noted, however, that the ulnar deformity begins at a 

higher level in this case than it does in Colles' fracture. The level of the ulnar fracture 

is not as apparent by inspection as it is when palpated. The lower ulnar fragment may 
be felt displaced backward. 




Pig. 300. — Fracture of both bones of the forearm near the wribt. Condition closely 
resembles Colles' fracture. Inspection and palpation of the ulnar side of the wrist dis- 
closes the break in the ulna and the backward displacement of the lower fragment. 



placement is that shown in Fig. 297 in which the forearm is bent 
forward instead of backward. Forward or backward displacement 
may take place and be pronounced without any element of over- 
riding in either bone. When however the hand and lower part 



FRACTURES OF RADIAL AND ULNAR SHAFTS 



217 




Fig. 302. 



Fi§s. 301 and 302. — Fracture of both bones of the forearm a short distance above 
the wrist with very slight deformity. Note the slight backwarfl bonding of the forearm. 




Fig. 303. — Upper arrow points to free radial styloid (anomalous). Lower arrow 
points to fracture of the shaft of the radius. 



218 



FRACTURES AND DISLOCATIOXS 



of the forearm are displaced to either the radial or ulnar side, the 
bone on the concave side of the forearm will nsually show over- 
riding deformity. If the displacement is a combination of antero- 
posterior and lateral (for example, if the hand is displaced 
backward and also to the radial side) it will be due either to over- 
riding and ano:ular deformitv of the shaft on the concave side of 




Figs. 304 and 305. — Green-stick fracture of the ulna in a child. This condition 
might be easily overlooked if the X-ray had not been employed. Lateral compression 
of the two bones, however, showed more '"spring"" than normal in the ulnar shaft. 
(See Fig. 307.) Comparison with the opposite ulna renders recognition of the condi- 
tion easier. 



the forearm, or else the fractures are at different levels and the 
forearm folds back diagonally. The nature of the deformity and 
the crease on the dorsal surface of the forearm will usually indi- 
cate the relative levels of the two fractures. This crease represents 
the apex of the angle of displacement and when the fractures are 
at the same level the crease will run transversely across the back 
of the forearm. When the fractures are at different levels the 



FRACTURES OF RADIAL AND ULNAR SHAFTS 219 

crease will be more or less obliquely placed. It is well shown in 
Figs. 271 and 277. In some instances the fragments of both bones 
will show only overriding deformity with thickening of the fore- 
arm where the fragments overlap. This thickening is often diffi- 
cult to distinguish from the usual swelling at the site of fracture, 
but the accompanying shortening of the forearm and the resultant 
flail-like condition will disclose the nature of the injury. An ex- 
cellent example of this condition is shown in Figs. 313 and 314. 
The loss of function is complete when both bones are broken and 
the attitude in which the patient supports the entire length of the 
forearm with the opposite member is characteristic. 

In '' green-stick' ' fractures of the forearm there is more or less 
bowing of the shafts of both bones, as a rule, either forward or 
backward. The deformity is seldom as distinctly angular as seen 
in adults but presents more of a curved effect. The condition is 
not flail-like and mobility is absent. The lateral spring of both 
bones, however, is usually increased. This increase in spring is 
particularly noticeable if pressure is made on the concave side of 
the deformity. The symptoms in children are occasionally quite 
mild, producing little more in the way of disability than would 
result from a bad sprain or bruising of the forearm. This fact 
calls attention to the necessity of a careful examination and the 
use of the X-raj^ in doubtful cases following injury of the forearm 
in a child. 

Diagnosis. — In making a diagnosis of fracture of the forearm the 
parts should be carefully and systematically examiined. There is 
much which can be learned by inspection alone since the majority 
of fractures in this region are accompanied by characteristic de- 
formities, as shown in the accompanying illustrations. The more 
the surgeon can gather by inspection the less there will remain 
to be determined by palpation and the shorter will be manipulation 
which only increases the damage to the already traumatized soft 
tissues. The deformities shown in the accompanying illustrations 
are not exceptional but represent the average run of cases, and a 
study of these photographs should be of service to the student in 
enabling him to recognize these conditions with the least possible 
disturbance of the parts. It is always advisable to have a Ront- 
genogram taken of the case to determine the accuracy of reduction, 
if not for the purposes of establishing a diagnosis. Theoretically 
an X-ray examination is of great value before reduction is at- 



220 FRACTURES AND DISLOCATIONS 

tempted, but practically the time necessary to secure such an 
examination often renders it inexpedient. The longer the deform- 
ity exists the greater the suffering and the more pronounced the 
secondary traumatic reaction. It is therefore incumbent on the 
surgeon to effect reduction at the earliest possible moment and to 
learn all that is possible by inspection and palpation before the 




Fig. 306. — Testing the spring in tlie bones of the forearm by means of lateral 
pressure. 

fragments are brought back into alignment. When one is accus- 
tomed to interpreting these deformities a successful reduction will 
often be possible before the X-ray is made, while, on the other 
hand, if these physical signs are neglected a secondary manipula- 
tion will usually be needed after the X-ray returns are available. 
Treatment. — Reduction of isolated fractures of the radius may 
be eas}^ or difficult according to the nature of the break and the 
displacement present. AYhen the fracture is high, the anterior dis- 
placing action of the biceps may require immobilization in a posi- 
tion just short of acute flexion. (See Fig. 210 and page 145 under 
Treatment of ''Fractures of the Lower End of the Humerus.") 
If the fracture is between the insertions of the biceps and pronator 
radii teres the condition is usually best treated with the forearm 
in a position of semiflexion and complete supination. (See 
"Anatomy" on page 205.) This places the lower fragment in a 
position of supination to correspond to the upper fragment which 
has been supinated by the biceps and supinator brevis. If the 
fracture in the radius is low, the upper end of the lower fragment 
may be displaced toward the ulna; strong traction on the wrist 



FRACTURES OF RADIAL AND ULNAR SHAFTS 221 

with adduction of the hand may be necessary to bring the lower 
fragment back into alignment. If reduction cannot be effected 
by manipulation operation is indicated. When the fracture is 
high the elbow should be immobilized, and when near the wTist it 
may be necessary to include the hand in the splint. The splints 
to be used and the precautions to be observed in applying them 
are the same as will be described shortly in the treatment of frac- 
tures of the shafts of both bones of the forearm. In instances in 
which the serrations are coarse there may be difficulty in securing 
a satisfactory engagement. Under these conditions reduction may 
sometimes be facilitated by temporarily increasing the angidar de- 
formity while attempting to engage the fractured ends. With the 
ends thus engaged the angular deformity is easily corrected since 
the ulna maintains the length of the forearm. 

The reduction of isolated fractures of the ulnar shaft is ac- 
complished in a manner similar to that employed in fractures of 
the radial shaft. Reduction is usually not attended by much 
difficulty as long as overriding of the fragments is prevented 
by an intact radius. Traction on the hand can accomplish noth- 
ing. Displacement of the lower fragment toward the radius is 
common and is to be corrected by digital pressure between the 
bones. It is often possible to secure an engagement of the ser- 
rated ends so that this deformity will not recur. Wlien the con- 
dition is compound it should be treated according to the principles 
laid down under the heading of ''The Treatment of Compound 
Fractures and Luxations," on page 789. 

Unfortunately fracture of the shafts of both hones of the fore- 
arm is much more common than fracture of either bone separately 
and the condition is more difficult to treat, not only because there 
are two bones to be reduced but because neither bone enjoys the 
supporting effect of the other. It is only by appreciating the dif- 
ferent types of deformity and what they indicate that one is 
qualified to return the fragments to their proper positions with 
the greatest accuracy and dispatch. When the deformity is purely 
angular and the fractures approximately transverse there will 
seldom be any difficulty in effecting reduction. Wh(Mi however 
there is overriding of one or both pairs of fragments correction 
of the displacement is much more difficult. The overriding de- 
formity should be reduced before the angular displacement is 
corrected. One is thus enabled to secure an engagement of the 



222 FRACTURES AND DISLOCATIONS 

serrated ends before tlie fragments are brought back into alignment. 
It should be remembered dnring all manipulations that the sharp 
serrated ends of the fragments may be made to do serious injury 
to the soft tissues. When it is found necessary to make lateral 
pressure on a fragment the force should be a])plied a little above 
or below the seat of fracture, as the case may be, and not directly 
on the displaced end. Fracture of the radius between the inser- 
tions of the biceps and pronator radii teres, calls for immobiliza- 
tion of the forearm in the supinated position, the same as already 
mentioned in the treatment of isolated fractures of the radial 
shaft. When the fragments of only one shaft are found to be 
overriding (more often the radius) our attention ma}^ be confined 
almost entirely to correcting the deformity of this one bone. The 
lateral displacement is first reduced and then the angular de- 
formity ; the opposite bone will follow provided it shows only 
angular displacement. When reduction is difficult or the patient 
nervous and hard to control it may be advisable to accomplish re- 
duction under anesthesia. It is well to remember that children 
are not as safe subjects for anesthesia as adults and reduction 
in many cases entails only an instant of pain if properly per- 
formed. In reducing green-stick fractures in children it may be 
possible to simply correct the bowing and straighten the bone but 
more often it will be found necessary to complete the fracture by 
bending the shaft in the direction of the bowing and then treat- 
ing the condition as a complete fracture. 

If the surgeon has reason to anticipate any special difficulty in 
effecting reduction it may be well to prepare for operation before 
giving the anesthetic, and then if it is found that reduction can- 
not be accomplished by manipulation he is ready to correct the 
displacement by open incision. Thus an additional anesthetic 
is avoided, time is saved and there are no failures to be explained. 

The splints employed in immobilization of fractures of the 
forearm are the same Avhether one or both bones are broken. Flat 
anterior and posterior splints will be found to meet the require- 
ments in the largest number of cases. They should be a little 
broader than the widest portion of the forearm and well padded 
before being applied. Light quarter-inch wood will answer the 
purpose well. Pliable wood such as yucca board may be em- 
ployed but should be used with the greatest caution and must never 
be bandaged in place tightly enough to force it to conform to the 



FRACTURES OF RADIAL AND ULNAR SHAFTS 223 

Appltcatiox of Splixts to the Forearm. 

Fis. 307. — Fracture of both hones of the forearm prior to reduction. (See Figs. 
385 and 386.) 




Fig-. 308. — Yentral splint appUed followino; reduction and held in position by two 
straps of adliesive — A. and B. 




Fig. 309. — Forearm turned so that thenar "cut-out" may he seen. 




Fig. 310. — Dorsal splint applied and held in position by two additional straps of 
idhesive — C. and D. 




Fig. 311. — Bandaging covering both splints. When the forearm is broken above the 
middle this dressing should be supplemented by an internal right angle splint. (See 
Fig. 2iaJ 



224 FRACTURES AND DISLOCATIONS 

contour of the forearm, as otherwise constriction may result. The 
anterior splint should extend from the middle of the palm of the 
hand to a point just below the bend of the elbow when the fore- 
arm is semiflexed. The radial side of the lower end of the splint 
should be cut away to clear the thenar eminence as shown in Fig. 
309. The cotton padding should be thicker just above the wrist 
and opposite the palm of the hand. The posterior splint should 
extend from the metacarpo-phalangeal knuckles to a point a short 
distance below the elbow. The forearm must not be bandaged 
before the splints are applied as the circulation may thus be in- 
terfered with. One splint is put in place (usually the palmar) 
and secured with two strips of adhesive as shown in Fig. 308 
and the parts examined to see that reduction is maintained. The 
second splint is then applied and secured with strips of adhesive 




Fig. 312. — Shows same dressing opened up for inspection during the after-treat- 
ment. Straps C. and D. have been cut and dorsal splint turned back, thus allowing 
inspection and palpation of the forearm while it is still secured to the ventral splint. 
(See also Figs. 283 and 284.) 

which encircle both splints. The splints should be loosely ban- 
daged, especially when the dressing is first applied. Gangrene 
of the forearm or Yolkmann's contracture may follow too tight 
bandaging, and the surgeon cannot always depend on the sensa- 
tions of the patient to give warning that damage is being done. 
Gangrene is known to have occurred without attracting the pa- 
tient's attention. Phlegmonous inflammation is not uncommon, 
and pus developing within tlie tissues may cause extensive dam- 
age by burrowing. It must be remembered in tliis connection that 
a bandage may be of the proper snugness at the time of applica- 
tion and yet a few hours "of swelling may result in dangerous 
strangulation of the forearm. Any form of splint which is curved 
to conform to the surface of the forearm, or a rolled bandage 
applied to the forearm before flat splints are put in place, is more 
likely to produce strangulation than is the simple flat splint. 
Splints making pressure between the bones of the forearm to 



FKACTURES OF RADIAL AND ULNAR SHAFTS 225 

prevent approximation of the fragments across the interosseous 
space are dangerous and should never be used. If the fracture or 
fractures are in the upper half of the forearm an internal or 
external right angle splint should be used in addition to the flat 
splints emploj'ed in immobilizing the forearm. If the break is 
near the elbow it will be impossible to secure proper fixation with- 
out immobilizing the elbow. The thumb and fingers should be left 
exposed in all cases so that the condition of the circulation may be 
known without removing the dressings. 

The secondary traumatic reaction is often pronounced in frac- 
tures of the forearm, and must be taken into consideration in the 
treatment of fractures in this region. If the trauma to the soft 
tissues is great it may be best to defer the application of splints 
until the swelling is decreasing and under control. It is often 
possible to foretell approximately the degree of swelling which will 
follow, by the extent of bruising of the tissues of the forearm, 
and when the surgeon has reason to anticipate a severe reaction 
the case should be treated for the first few days along the follow- 
ing lines. The deformity is reduced immediately and the forearm 
loosely bandaged on a single splint. The patient is then put 
to bed, the parts kept perfectly quiet and the ice cap applied 
at intervals to the region of fracture. Sedatives or opiates may 
be necessary if the pain is severe. The arm should be examined 
every few hours to see that the swelling is not great enough to 
cause constriction of the forearm within the bandages. During 
this time an X-ray should be taken to determine the exact nature 
of the fracture. When the swelling is well subsided the arm may 
be immobilized with splints as previously described. 

Operative Treatment. — The open method is indicated in recent 
cases when proper reduction cannot be had by manipulation and 
in compound cases. Simple angular deformity can, as a rule, be 
corrected by manipulation unless some of the soft tissues become 
interposed between the fractured surfaces. Overriding deformity 
of one or both bones and multiple fracture of one of the shafts 
are the conditions most often rendering operation necessary. 
Fracture of the radius is best exposed through a longitudinal inci- 
sion on the outer aspect of the forearm. The skin, fasciae and 
aponeuroses are divided with the scalpiel and the underlying mus- 
cles separated by blunt dissection. When the fracture is low in 
the radial shaft care should be taken not to divide the tendons of 



226 ■ FRACTURES AND DISLOCATIONS 

the extensor muscles of the thumb which pass obliquely across 
the outer aspect of the lower end of the radius. The position 
of the radial pulse should be noted before making the incision to 
avoid injury to the artery when anomalously placed. With the 
fragments exposed reduction is accomplished by direct manipula- 
tion and the serrations fitted accurately together. Internal fixa- 
tion will usually be unnecessarj^ if the ulna has not been injured. 
Not infrequently one or both fragments show a disposition to slip 
out of place toward the ulna. When this occurs it may be possible 
to prevent recurrence of deformity by a single loop of wire holding 
the fractured surfaces opposed or it may be necessary to emplo}^ a 
small, light Lane plate. 

In operating on the ulnar shaft it is best to expose the frag- 
ments through a longitudinal incision a little internal to the pos- 
terior subcutaneous border. The fragments are reduced in a man- 
ner similar to that just described in operating on the radial shaft, 
and internal fixation used or not, according to the needs of the 
case in hand. 

When hoth hones are fractured the shafts should be exposed 
through two incisions as already described in operating on isolated 
fractures of either shaft. It is a mistake to attempt to expose 
both shafts through one incision since the injury to the soft tissues 
will be more extensive. Theoretically this would not seem to be 
the case, but practically it will be found to be true. Internal 
fixation is more frequently necessary when both bones are frac- 
tured than in instances of isolated fracture of either the radial or 
ulnar shaft. 

In severe compound cases where there has been considerable loss 
of bony tissue in one of the shafts it has often been found neces- 
sary to resect a portion of the opposite shaft to make the two bones 
of equal length. This procedure has in many instances resulted in 
useful arms which would otherwise have been severely crippled, 
but before it is employed in any given case we should consider 
the possibility of an autoplastic transplantation of a portion of the 
shaft of the patient's fibula or a section of the tibial crest into the 
shaft of the deficient bone. (See ''Bone Transplantation" on page 
771.) 

Severe compound cases should be treated according to the prin- 
ciples laid down under the heading of "The Treatment of Com- 
pound Fractures and Luxations" on page 789. Severed arteries 



FRACTURES OF RADIAL AND ULNAR SHAFTS 



227 



lie fdrearm with 




Fig. 315. — Antero-posterior view of same case after operation and internal fixatior 





T«»»5»»53'^B'- 



Fig. 316. — Lateral view after operation. 



228 FRACTURES AND DISLOCATIONS 

should be ligated and nerves sutured in cases where the^^ are found 
divided. 

After-Treatment. — During the first few days the bandages should 
be very loose and the dressings frequently inspected to see that 
there is no strangulation of the parts. The condition of the cir- 
culation beneath the nails may be easily ascertained and compared 
with the opposite side. There is no region in the body in which 
strangulation is more likely to take place than in the forearm and 
the results may be disastrous. Volkmann's contracture is a pos- 
sibility which must be kept constantly in mind during the after- 
treatment of fractures of the forearm. (See "Volkmann's Con- 
tracture," page 231.) The skin over the head' of the ulna often 
calls for special care to avoid irritation. Gentle massage after the 
subsidence of the traumatic swelling is of great value in keeping 
the soft tissues in good condition during the process of bone heal- 
ing but the greatest care should be exercised to avoid disturbing 
the fragments. Union may be expected in children in three weeks 
or even less, but the forearm should be protected by retaining the 
posterior splint for another ten days. The forearm should be sub- 
jected to only the gentlest use for two or three weeks following the 
removal of all splints. Active motion in all directions will be 
weak and limited on removal of the splints, but function will 
return rapidly with use and massage. The parts should be in- 
spected at least daily for the first ten days to properly accommo- 
date the dressings to the varying size of the forearm; after ten 
days the dressings should be removed at least twice a week to 
recognize and correct deformity, should it take place. If flat 
splints are used, as shown in Figs. 283 and 312, one splint may be 
removed without disturbing the other, and we are thus enabled to 
inspect the parts without entirely removing the support from the 
broken bones. Plaster splints and the plaster cast have been suc- 
cessfully used in the treatment of fractures of the forearm but they 
are dangerous appliances except in the hands of the expert. If 
plaster of Paris had never been employed in the treatment of 
fractures of the forearm Volkmann's contracture would have been 
much less common. 

If the fractures are at or above the middle of the shafts the 
internal or external right angle splint should be retained through- 
out as a necessary part of the dressing. 

Bowing may result from using the forearm too soon and the 



FRACTURES OF RADIAL AND ULNAR SHAFTS 



229 



patient should be warned to avoid undue strain on the bones for 
a period varying from one to four months following fracture. 
When there is doubt as to the satisfactory ossification of the callus 
it is advisable to base our after-treatment on X-ray findings. In 
adults four to five weeks will be necessary before the callus is 
strong enough to allow^ permanent removal of the splints. Old 
persons produce bone slowly and should be allowed 15 to 20 per- 




Fig. 317. — Slight bowing deformity following fracture of both bones of the fore- 
arm. The deformity here is due to overriding of the radial fragments. Note the hand 
which is displaced slightly to the radial side and a little backward. Operation was 
advised in this case but refused. Function restored but slight deformity persists. A 
deformity such as this will diminish with years provided the patient is young. Picture 
taken about four and a half weeks following fracture. 



cent more time than is allowed healthy adults. During the after- 
treatment the fingers should be manipulated daily, especially in old 
persons, as otherwise adhesions form about the tendons and mus- 
cles and between the joint surfaces, which may prove a permanent 
source of restricted motion. 

Prognosis. — The prognosis in fractures of the bones of the fore- 
arm varies greatly according to the conditions present. Accurate 
reduction of the fragments in a healthy child or adult should be 



230 



FRACTURES AXD DISLOCATIOXS 



followed by complete restoration of function. Deformity may pro- 
dnce loss of function. The rotary action of the forearm is most 
frecjuently interfered with, the most common causes being an 
outward bowing of the shaft of the radius or the extension of the 
callus from the shaft of the ulna to the radius when the fragments 
of these two bones are displaced toward each other. Loss of the 




319 (top), 



Fig. 320. 



Figs. 318. 319 and 320. — Tliree views of a case of Volkmaun's paralysis. This case 
is an example of a most disastrous condition Avhieh may follow too tight bandaging of 
the forearm. In this case there had been no fracture. The patient sustained a lacerated 
wound involving one of the large arteries and an Esmarch tourniquet was applied and 
left in position for over twelve hours while the patient was being brought to the city 
for surgical treatment. ^Myositis, paralysis and contracture followed. Case first seen 
by author some years after the injury. 



power of supination may follow fracture of the radial shaft be- 
tween the insertions of the biceps and pronator radii teres if not 
treated in supination as previously mentioned. Xon-union of frac- 
tures of the forearm is not common but when it does take place it 
is usually the result of the interposition of soft tissues between the 
fractured ends rather than to constitutional causes or defective 
immobilization. When due to the interposition of muscle or fascia 
the prognosis will depend on whether or not operative procedures 
are instituted and the fractured surfaces brought into contact. A 
careful study of X-ray plates taken in two planes will as a rule 
disclose the presence of interposed tissues early in the course of 
the case, and if the proper surgical measures are then instituted 



FRACTURES OF RADIAL AND ULNAR SHAFTS 231 

there will be no occasion for non-union. Slight bowing in a child 
will usually correct itself as j^ears go by but this fortunate condi- 
tion is no reason for the surgeon not insisting on the most perfect 
possible reduction following the accident. 

Yolkmann's paralysis (or contracture) is a paralysis of the fore- 
arm with wasting of the muscles and contracture. The first cause 
is said to be an ischemia which is followed by myositis and ultimate 
destruction of muscular tissue which is replaced by scar tissue. 
The function of the nerves may be subsequently destroyed by con- 
traction of the scar tissue as well as by disuse. The points at which 
nerve constriction most commonly takes place are where the median 
passes between the heads of the pronator radii teres, and the ulnar 
nerve between the heads of the flexor carpi ulnaris. Volkmann's 
paralysis usually follows fractures of the upper extremity in chil- 
dren (especially fractures of the forearm) and is the result of too 
tight bandaging or interference with the circulation from some 
other cause. 

Pain may be present with the onset of the condition, but is no 
guide whatever to the damage the forearm may be undergoing 
from too tight bandaging. The fingers are swollen and show passive 
congestion, the hand and forearm are numb and uncomfortable but 
seldom painful. Later on contracture develops in which the wrist 
is flexed, the proximal row of phalanges hyperextended and the 
middle and distal rows flexed. (See Figs. 318, 319 and 320.) If 
the condition is allowed to go uncorrected, contraction of the scar 
tissue replacing the muscles is likely to destroy the nerves, and all 
electric reaction will be lost. 

If the case is seen early (within a few days or a week), massage 
and forcible passive motion with removal of all dressing, regardless 
of the presence of fracture, should be followed by complete restora- 
tion of function. If the case is first seen after the establishment of 
the contracture, surgical measures will be necessary, and even then 
the restoration of function is usually only partial. The condition of 
the nerves should be determined and then the procedure most likely 
to give good results chosen. Myotomy may be performed, the 
nerves may be dissected out, the flexor tendons may be lengthened 
or the radius and ulna may be shortened. Passive motion and 
massage are most important following operation. 



GHAPTEE XYII. 

FRACTURES OF THE LOAA^ER END OF THE ULNA. 

Surgical Anatomy. — Isolated fracture of the lower end of the 
ulna is not a common injury and its importance is much less than 
fractures of the lower end of the radius. Uncomplicated fracture 
in this region is almost invariably due to direct violence. The 
lower end of the ulna is only slightly larger than the shaft above 
it and transverse stress is about the only type of strain to which 
it is subjected. It forms the center about which the lower end 
of the radius revolves during supination and pronation. Longi- 
tudinal stress, such as sustained in falls on the hand, is transmitted 
through the radius directly to the humerus, and from the radius 
to the ulnar shaft by means of the interosseous membrane. The 
lower end of the ulna remains free from this type of strain, be- 
coming involved only when the radius breaks; the pull of the 
triangular fibro-cartilage may then fracture the ulnar styloid. 
The lower end of the ulna does not enter into the formation of the 
wrist joint but articulates with the upper surface of the triangular 
fibro-cartilage and the sigmoid cavity of the radius. In pronation, 
the head of the ulna presents at the back of the wrist, while in 
supination the styloid process alone is palpable. Fractures of the 
lower end of the ulna are often situated just above the head and 
are usually transverse, though they may be oblique or longitudinal 
and involve the head or styloid process. The most common break 
of this portion of the ulna is seen accompanying Colles' fracture 
and consists in an avulsion of the styloid. (See Figs. 326 to 331.) 

Epiphyseal separations may occur but are quite rare. The lower 
epiphysis (including the head and styloid) is ossified from a single 
center which is first seen about the fourth year. It joins the shaft 
at about the twentieth year. An anomalous ossicle, the triangulare, 
is sometimes seen just below the tip of the ulnar styloid and may 
be mistaken for fracture of this process in interpreting X-ray 
plates of this region. (See Figs. 405 and 406.) 

On the posterior aspect of the lower end of the bone is a shallow 

232 



FRACTURES OF LOWER END OF ULNA 



233 




Fig. 321. — Fracture of both bones of the forearm and separation of the lower ulnar 
epiphysis. The separated epiphysis forms a slight prominence on the ulnar side of the 
wrist Avliieli may be seen and felt. Photogi-aph taken a few minutes following accident. 




Fig. 323. 

Figs. 322 and 323. — X-ray plates showing antero-posterio 
case seen in Fig. 321. 1 and 2, fracture in ulnar shaft; 3 
shaft; 5, displaced ulnar epiphysis. 



■ and lateral views 
and 4, fracture in 



of the 
radial 



234 FRACTURES AND DISLOCATIONS 

groove for the passage of the tendon of the extensor carpi ulnaris. 
Symptoms. — The symptoms accompanying isolated fracture of 
the lower end of the ulna are often surprisingly mild. There is 
local pain, tenderness, swelling and a variable degree of loss of 
function. Since the condition usually results from direct violence 
there will, as a rule, be evidences of the blow on the skin in this 
region. If the trauma is severe the condition may be compound. 
Supination and pronation are often particularly painful and the 




Fig. 324. — Fracture and separation of a portion of the ulnar epiphysis including 
the styloid process. 

wrist lacks lateral stability though the movements of the wrist 
itself are mechanically undisturbed. Direct palpation will elicit 
crepitus if the fragments are manipulated. The lower end of the 
upper fragment may be displaced in any direction though it is 
more common to find it nearer the radius than normal and x:)rom- 
inent posteriorly. Deformity, however, is usually slight. 

Diagnosis. — Fracture of the lower end of the ulna can, as a rule, 
be recognized without difficulty if the parts are carefully exam- 
ined. There is no characteristic deformity and hence inspection 



FRACTURES OF LOWER END OF ULNA 235 

alone is of little value. The condition is most frequently over- 
looked when it occurs accompanying CoUes' fracture. The broad- 
ening of the wrist seen in Colles' fracture is due to rupture of the 
triangular fibro-cartilage or to avulsion of the styloid (usually 
the latter) and is suggestive of fracture of the lower end of the 
ulna. When doubt exists the X-ray should be employed. 

Treatment. — This fracture is not a serious one as compared to 
other breaks in this region and reduction of the displacement is 
usually accomplished without difficulty. If the tendon of the 
extensor carpi ulnaris tends to displace the lower fragment the 
hand should be treated in a position oi dorsal flexion and ad- 
duction. A single anterior splint extending from the base of the 
fingers to the upper part of the forearm will usually suffice in 
immobilizing the parts. Direct pressure may be exerted by pads 
of gauze secured in position by strips of adhesive plaster. Direct 
pressure is not often indicated, but when it is it will usually be 
found necessary because of a tendency on the part of the lower end 
of the upper fragment to backward deformity. Under these cir- 
cumstances direct pressure should be exerted on the shaft of the 
bone above the level of the fracture. Tight bandaging is as dan- 
gerous here as in the treatment of fractures of the shafts of the 
bones of the forearm, and the same precautions are to be observed 
as already mentioned in the preceding section. The forearm 
should be carried in a sling which supports its entire length as 
otherwise it may exert a displacing action on the fragments. 

Operative Treatment. — Open treatment is rarely indicated in 
recent cases aside from compound conditions. When the fracture 
is open it is to be treated according to the principles laid down 
under "The Treatment of Compound Fractures and Luxations," 
on page 789. If deformity recurs or persists and cannot be con- 
trolled by ordinary methods the fragments should be secured by 
internal fixation (see page 754). 

After-Treatment.— The forearm should be frequently inspected 
during the first week or ten days, especially if the secondary 
traumatic reaction is pronounced. Undue constriction of the fore- 
arm is as dangerous here as in fractures of the shafts of the bones 
of the forearm and may lead to Volkmann's Contracture (see 
page 230). Immobilization for three to four weeks should result 
in union. Fracture of the styloid and displacement of the lower 
end of the ulna will be considered under "Fractures of the Lower 



236 FRACTURES AND DISLOCATIONS 

End of the Radius," since it most frequently occurs as a compli- 
cation of Colles' fracture. 

Prognosis. — The outlook in uncomplicated fracture of the lower 
end of the ulna is good both as to function and deformity. Fibrous 
union is sometimes seen but does not as a rule materially lessen 
function. When the condition is compound the prognosis is of 
course worse, but it is rare to see disability following fractures in 
this region. 



CHAPTER XYIII. 

LUXATIONS OF THE LOWER END OF THE ULNA. 

Surgical Anatomy. — The lower end of the ulna articulates with 
the superior surface of the triangular fibro-cartilage and the sig- 
moid cavit}^ of the radius. The lower end of the radius describes 
an arc about the head of the ulna during supination and pronation 
and the center of the arc thus described is the attachment of the 
apex of the triangular fibro-cartilage in the depression between 
the ulnar head and styloid. This triangular cartilage is the 
only ligament in the lower radio-ulnar articulation which main- 
tains the ends of the bones in apposition. The anterior and pos- 
terior radio-ulnar ligaments extend transversely in front of, and 
behind, the joint and limit its rotary action. The lower end of 
the ulna does not enter into the formation of the w^rist joint. A 
separate synovial sac exists between the lower end of the ulna and 
the cartilage, and extends upward between the radius and ulna. 
Isolated luxation of the lower end of the ulna is an extremely rare 
accident though it has been recorded in a sufficient number of 
cases to establish it as a type. A more or less complete dislocation 
of this joint is not an uncommon complication of Colles' fracture 
and is the result of rupture of the triangular fibro-cartilage or an 
avulsion of its ulnar attachment. This condition has been fully 
considered under "Fractures of the Lower End of the Radius," 
(page 242), and appropriately so, since it is secondary to and a 
complication of Colles' fracture. 

It is probable that no one observer has seen more than one un- 
complicated luxation of the low^er end of the ulna and hence the 
details of the condition are not as well known as they might be. 
The author has seen but one case. Experiments which the author 
has conducted on the cadaver showed that rupture of the tri- 
angular fibro-cartilage or avulsion of one of its attachments w^as 
necessary for inward luxation. Rupture of the posterior radio- 
ulnar ligament was regularly found in posterior dislocations and 
tearing of the anterior ligament w^as noted in forward luxations. 

237 



238 FKACTURES AND DISLOCATIONS 

Extreme pronation produced tension on the posterior fibres of the 
triangular fibro-cartilage while extreme supination rendered the 
anterior fibres taut. Eeduction was accompanied by a distinct 
snap in all cases in which the triangular fibro-cartilage remained 
unruptured. 

Clinically, three types of luxation of the lower end of the ulna 
have been observed : — namely, backward, forward and inward. In 
the hackward type the head occupies a position just behind the 
postero-internal angle of the quadrilateral lower end of the radius. 
The posterior ligament is torn while the triangular fibro-cartilage 
remains intact. This type of luxation is more commonly seen as 
a complication of ''reversed Colles' fracture" and is due to hyper- 
pronation of the wrist. In the forward type of luxation the 
lower end of the ulna is displaced forward and slightly outward, 
and in isolated cases is probably caused by hypersupination. As 
a complication of fracture of the lower end of the radius it is not 
uncommon. The inivard type occurs only with rupture of the 
interarticular cartilage and as an isolated injury is so rare as to be 
questionable. As a complication of Colles' fracture it is not at 
all uncommon. 

Symptoms. — The symptoms accompanying luxations of the lower 
end of the ulna depend on the length of time the displacement 
has persisted and the position occupied by the head of the ulna. 
In recent cases there is pain, swelling, tenderness, loss of func- 




Fig. 325. — Posterior luxation of louver end of ulna. Xote the abnormal prominence 
at the back of the -vvrist on the ulnar side. 

tion, etc. The deformity and disturbance in function depend on 
the type of luxation. In the hacl'icard variety the wrist is in 
extreme pronation, narrower than normal and the prominence of 
the displaced head is apparent. The hand is slightlv adducted. 



LUXATIONS OF LOWER END OF ULNA 239 

supination is impossible as long- as the luxation exists, and there 
is loss of power in the fingers and wrist. In the forward type the 
forearm is fixed in supination and the ulnar head may be palpated 
on the palmar aspect of the wrist above the pisiform. The wrist 
appears narrower than normal and the absence of the ulnar head 
from its normal position is apparent. The inward type of luxa- 
tion shows a broadening of the wrist with loss of power in the 
rotary action of the forearm. The symptoms of inward luxation 
are a part of the clinical picture in many cases of Colles' fracture, 
and as such have been described under "Fractures of the Lower 
End of the Radius." As an isolated injury this dislocation is a 
surgical curiosity. 

Chronic and recurrent luxations of the lower end of the ulna 
are occasionally seen and the symptoms differ considerably from 
the acute condition. A chronic backward subluxation is sometimes 
seen in children as a result of heavy work while the bones are 
still in a soft and developmental stag:e and is known as Madelung's 
deformity. This backward displacement develops gradually as the 
radial deformity increases, and with removal of longitudinal pres- 
sure the ulna grows proportionately faster than the radius. 

Recurrent luxation of the lower end of the ulna is an extremely 
rare condition sometimes seen following" trauma in this region. 
The displacement is usually not pronounced, but the lower end of 
the ulna is likely to slip out of position with extreme supination 
or pronation. Reduction is easy and usually accomplished by the 
patient. The annoyance and interference with function may be 
marked and is sometimes accompanied by ulnar neuritis. 

Diagnosis. — There should be little difficulty in recognizing dislo- 
cations of the lower end of the ulna. The displaced head of the 
bone may be palpated and is characteristic of the luxation accord- 
ing to the direction of displacement. In the forward type the 
wrist is narrower than normal and fixed in supination. In the 
backward type it is narrower than normal and fixed in pronation. 
The broadening of the wrist is typical of inward luxations which 
are almost never seen except as a complication of Colles' fracture. 
Luxations of this joint are most frequently overlooked when they 
exist as complications of Colles' fracture, and this is because one 
is apt to feel that the diagnosis is complete as soon as the fracture 
has been recognized. 

Treatment. — The method of reduction will depend on the type 



240 FRACTURES AXD DISLOCATIONS 

of luxation present. In backward dislocations pressure should be 
exerted witli the thumbs to force the lower ends of the bones apart 
while the wrist is being carried into supination. The object is 
to force the head of the ulna around the postero-internal angle 
of the lower end of the radius and then carry the forearm into 
supination. Reduction is accompanied by a distinct snap as the 
ulnar head clears the prominence and settles back into the sig- 
moid cavity of the radius. Reduction of the anterior luxation is 
accomplished by forcing the ulnar head backward and inward 
around the antero-internal angle of the lower end of the radius 
and then carrying the forearm into pronation. Reduction of this 
luxation is also accompanied by a distinct snap if the triangular 
fibro-cartilage is not ruptured. Uncomplicated inward luxation of 
the head of the ulna would probably offer little or no resistance to 
reduction and the tendency to recurrence would be slight. The 
condition, however, is practically unknown as an isolated injury. 
When it occurs as a complication of Colles* fracture it is difficult 
to keep the luxated ulnar head in position because the radius has 
been shortened by fracture. In recent cases there is little tend- 
ency to recurrence of deformity if the luxation is either forward 
or backward. In old cases it may be impossible to effect reduction 
by manipulation, especially if the ulna has outgrown the radius in 
length. 

Operative Treatment. — Operative treatment is practically never 
indicated in recent cases unless the condition is a complication 
of Colles' fracture and the break calls for open treatment to 
effect or maintain reduction. In old unreduced luxations and 
when the condition is congenital it imay be necessary to operate to 
restore the bones to their normal relations. In old cases it may be 
necessary to resect the ulnar head when the ulna has outgrown 
the radius. With the end of the bone removed reduction may be 
accomplished and recurrence of deformity prevented by suturing 
the soft tissues. In recurrent cases it may be possible to shorten 
the lower radio-ulnar ligaments or their tension may be increased 
by dividing the radius about two inches from the lower end and 
tipping the lower fragment so that the styloid will occupy a lower 
level. 

After-Treatment. — In recent forward or backward luxations the 
deformity does not tend to recur and hence no special retentive 
apparatus will be required aside from avoiding extreme supination 



LUXATIONS OF LOWER END OF ULNA 241 

or pronation according to the type of luxation. Should a tend- 
ency to recurrence be present the forearm should be immobilized 
in a position of rotation opposite to that in which the luxation 
occurred. A backward dislocation should be fixed in supination 
while an anterior luxation should be immobilized in pronation. 
Two to three weeks should be allowed for the ligaments to heal. 
Following operation the forearm should be immobilized for two or 
three weeks, or even longer in exceptional cases. If the condition 
is compound it should be treated according to the principles laid 
down in "The Treatment of Compound Fractures and Luxations," 
on page 789. 

Prognosis.— The outlook in uncomplicated luxations of the lower 
end of the ulna is excellent if reduction is accomplished early. 
Old unreduced cases of forward or backward luxation usually show 
considerable disturbance in function especially in the rotary action 
of the forearm. In congenital luxations the loss of function is 
often surprisingly slight, consisting for the most part in loss of 
complete supination, slight weakness of the wrist and of early 
tiring when heavy work is performed. The same type of symptoms 
prevail in the backward subluxation seen in children as a result 
of heavy work during the years when the bones are soft. The 
operations recorded have been few but the results are encouraging. 



CHAPTER XIX. 

FEACTURES OF THE LOWER END OF THE RADIUS. 

Surgical Anatomy. — The region of the wrist is compact and 
contains numerous tendons, nerves and vessels in close relation with 
the radius, ulna and carpus. The normal relations of these struc- 
tures and the surface landmarks should be known before one is 
qualified to recognize and fully appreciate the deformities accom- 
panying fractures of the lower end of the radius. Variations 
within normal limits are common in the lower ends of the radius 
and ulna, and the carpus is frequently the seat of pronounced 
anomalies. It is necessary, therefore, that the opposite w^rist be 
examined carefully before determining the conditions present in 
the injured member. The styloid process of the radius normally 
occupies a lower level than the ulnar styloid. Nearly all fractures 
of the lower end of the radius are accompanied by an elevation of 
the radial styloid; this condition is determined by comparing the 
relative levels of the two styloid processes as shown in Fig. 376. 
The uninjured wrist is used as the standard of comparison in as- 
certaining the distance the radial styloid has been raised. On the 
anterior surface of the wrist wall be noted two eminences. To the 
radial side is the thenar eminence; the upper margin of which is 
at a slightly lower level than the corresponding margin of the 
hypothenar eminence which is situated at the ulnar side of the 
wrist. When the outer side of the forearm is shortened by frac- 
ture of the radius the thenar eminence is raised according to the 
extent of the deformity. The outer aspect of the lower end of 
the radius is the only portion of the bone which is strictly sub- 
cutaneous, yet the lower half of the radius may be palpated with- 
out difficulty since there is little else than tendons interposed 
between the skin and the bone. 

On the posterior surface of the lower expanded quadrilateral 
extremity of the radius are a number of vertical grooves for the 
accommodation of the extensor tendons passing from the fore- 
arm to the hand. At about the middle of this surface will be 

242 



FRACTURES OF LOWER END OF RADIUS 



243 



noted a prominent ridge which forms the outer margin of the 
groove for the passage of the extensor longus pollieis. The tendons 
of the extensor ossis metacarpi pollieis and extensor brevis pollieis 
pass to the outer side of the radius, obliquely across the base of 




Fig. 329 



Fig. 330. 



Fig. 326. — Impacted fracture of lower end of radius. Fracture of ulnar styloid. 

Fig. 327. — Pronounced impaction of lower end of radius. Fracture of ulnar styloid 
at its base. 

Fig. 328. — Fracture of ulnar side of lower end of radius and fracture of ulnar 
styloid. 

Fig. 329. — ^Vertical fracture of lower end of radius and fracture of ulnar styloid. 

Fig. 330. — Comminution of lower end of radius and fracture of ulnar styloid. 

Fig. 331. — Extensive splitting and comminution of lower end of radius and frac- 
ture of ulnar styloid. 



the styloid process. The flexor tendons, radial artery, and median 
nerve pass in front of the lower end of the bone. The radial 
nerve as it courses down the outer side of the forearm and under 
the tendon of the supinator longus is sometimes injured and may 



244 



FRACTURES AND DISLOCATIONS 



give rise to considerable pain during the after-treatment. The 
inner aspect of the lower end of the radius presents the "sigmoid 




Fig. 33 



Figs. 332, 333 and 334. — Three good examples of Reversed Colles' fracture. The 
"gardener's spade" deformity is present instead of the "silver-fork" deformity. 




Fig. 385. 



Fig. 336. 



Figs. 335 and 336.— Antero-posterior and lateral vievrs of a fracture of the lower 
end of the radius produced by an "auto-kick." 



cavity of the radius" for articulation with the head of the ulna; 
just beneath the lower margin of this surface is attached the base 
of the triangular fibro-cartilage, which binds the radius and ulna 



FRACTURES OF LOWER END OF RADIUS 



245 



tog-ether. With the forearm semipronatecl the ulnar styloid may 
be palpated as a prominence of bone which is continuous with the 
posterior subcutaneous border of the ulna. The tip of the process 
is on a level with the articulation of the wrist. When the forearm 
is carried into complete pronation the ulnar head, instead of the 
styloid process, presents beneath the skin. The inferior surface 
of the lower end of the radius articulates with the upper row of 
carpal bones and looks downward and slightly forward. 

The internal structure of the lower end of tlie radius should be 
studied to fully appreciate the mechanism of fractures of this 




Figs. 337, 338 and 339. — Three views of a transverse CoUes' fracture with impaction 
of the proximal fragment into the cancellous tissue of the distal fragment. 



region. A short distance above the lower end of the bone tlie sur- 
face layer of compact tissue changes rapidly into the heavy tube 
of compact bone which forms the shaft of the radius, and it is 
here that fracture most often occurs. It is not uncommon to find 
the end of the upper fragment driven into the lower fragment, 
which means a more or less extensive crushing and comminution of 
the cancellous tissue in the lower end of the radius, and accounts to 
some extent for the tendency to recurrence of deformity following 
reduction. Thus, when the lower fragment is pulled back into 
position following impaction, there is a wedge-shaped space in the 



246 



FRACTURES AND DISLOCATIONS 



lower fragment corresponding to the crushed cancellous tissue, and 
"unless the layer of compact bone on the posterior aspect of the 
lower fragment is firmly engaged the deformity will return when 
the parts are released. A consideration of the internal structure 
of the lower end of the radius as shown in Figs. 268 and 384 
will explain this tendency to recurrence of deformity, and the 
necessity for overcorrecting the displacement so that the dorsal 
layer of compact tissue may properly engage the upper fragment. 




Fig. 340. — Fracture of lower end of radius produced by "auto-kick. 



Fractures in this region of the skeleton show considerable varia- 
tion, but the overwhelming majority corres])oiids, more or less 
closely to the type described by CoUes. His original description 
in 1814 was of a fracture one and a half inches above the articular 
surface, but subsequent experience has shown that the usual break 
is within three-fourths of an inch of tlie lower end of the bone. 
At the present time, therefore, Colles' name is used to indicate 
a condition slightly different from the one originally described by 



FRACTURES OF LOWER END OF RADIUS 



247 



him. The typical Colles' fracture is transverse or oblique, does 
not enter the articular surface and is accompanied by a backward 





Fig. 341. 



Fig. 342. 



Figs. 341 and 342. — Lateral and antero-posterior views of Colles' fracture with 
very slight deformity. Note fracture of ulnar styloid. 




Fig. 343. — CoUes' fracture with comminution of the distal fragment. 

displacement of the lower fragment. This backward displacement 
of the distal fragment produces the typical ^'silver-fork" deformity 
which is so characteristic of Colles' fracture (see Figs. 354 to 367). 



248 



FRACTURES AND DISLOCATIONS 







•^ , 



Fig. 344. 



Pig. 345. 



Figs. 344 and 345. — Antero-posterior and lateral views of transverse Colles' fracture 
with impaction of upper fragment into lower, after attempt at reduction. Same case as 
shown in Fig. 355. 




Fig. 347. 



Figs. 346 and 347. — -Antero-posterior and lateral views of oblique Colles' fracture 
after reduction. Same case as shown in Figs. 366 and 367 before reduction. Note 
obliquity of plane of fracture and absence of crushing of cancellous tissue by impaction. 



FRACTURES OF LOWER END OF RADIUS 



249 



The nature of the deformity varies somewhat with the line of frac- 
ture (see ''Symptoms," page 252). 

The usual Colles' fracture is the result of a fall on the out- 
stretched hand. If the fall is sustained on the palm of the haiuL 




Fig. 348. 



Fig. 349. 



Figs. 348 and 349. — Antero-posterior and lateral views of separation of lower radial 
epiphysis complicated by fracture of the end of the diaphysis. Same case as shown in 
Figs. 368, 869 and 370. 

as is usual, the distal fragment is displaced backward and the 
typical Colles' fracture is the result. If impaction is present 
it is the cancellous tissue near the posterior surface of tlie lower 
fragment which suffers most. In rare instances the distal frag- 



250 



FRACTURES AND DISLOCATIONS 




Fig. 350. 



. 351. 



Figs. 350 and 351. — Antero-posterior and lateral views of epiphyseal separation of 
lower end of radius complicated by fracture of the lower end of the diaphysis. Deform- 
ity corresponds to "reversed Colles'." 




Fig. 353. 



Figs. 352 and 353. — Antero-posterior and lateral views of separation of the lower 
radial epiphysis after reduction. Note the complicating fractures of both epiphysis and 
diaphysis. 



FRACTURES OF LOWER END OF RADIUS 251 

ment may be displaced veiitrally and the condition is then spolven 
of as a "reversed Colles' fracture." This type of deformity is 
usually produced when the causative trauma is received on the 
dorsal aspect of the hand with the wrist in flexion. Examples of 
reversed Colles' fracture are shown in Figs. 332 to 334. 

An oblique fracture passing from the posterior surface of the 
lower end of the radius into the articular surface, with dorsal dis- 
placement of the fragment, is known as Barton's fracture. When 
the break enters the articular surface from the anterior aspect of 
the lower end of the radius, with ventral displacement of the frag- 
ment, the condition is spoken of as a "reversed Barton's fracture." 
This terminology is rather unfortunate since these two conditions 
are in reality luxations of the wrist complicated by fracture of 
the lower end of the radius. Thus Barton's fracture is a backward 
luxation with fracture of the posterior lip of the radius, while 
reversed Barton's fracture is an anterior luxation with fracture of 
the anterior lip of the radius. The mechanism of Barton's frac- 
ture ^nd reversed Barton's fracture is similar to that obtaining in 
Colles' fracture and its reversed form. 

Atypical fractures of the lower end of the radius show con- 
siderable variation: the styloid process may be broken off, a ver- 
tical fracture may pass from the shaft into the articular surface, 
oblique fractures may pass from either the inner or outer aspect 
of the bone into the articular surface, the distal fragment of a 
Colles' fracture may be broken into two or more pieces or may be 
extensively comminuted, and the same condition sometimes exists 
in a separated epiphysis, and finally the lower end of the bone may 
be so extensively comminuted that it does not resemble any of the 
above described fractures. In some rare instances the ^upper 
row of carpal bones have been driven upward through the articular 
surface of the radius so that they rested partially within the can- 
cellous tissue of the lower end of the bone. In many of these 
atypical fractures the degree and nature of the defojmiity depend 
largely on the severity and direction of the causative trauma. 

The lower epiphysis of the radius is ossified by a single center 
which makes its appearance about the end of the second year. The 
epiphyseal cartilage is obliterated during the twentieth year. The 
causes of epiphyseal separations are similar to those producing 
Colles' fracture, and the deformity usually consists in a backward 
displacement of the lower fragment. It is not uncommon to find 



252 



FRACTURES AND DISLOCATIONS 



epiphyseal separations of the lower end of the radius complicated 
by fracture ; examples of this condition are shown in Figs. 348 
to 353. 

Symptoms. — The patient almost invariably gives a history of 
having fallen on the outstretched hand. The injury is followed 
immediately by severe pain and loss of function, and the sufferer 




i^'ig. 354. — 'iypical Colles" fracture a few minutes following the accident. Fracture 
transverse and impaction present. Compare this deformity with the other Colles' frac- 
tures shown in this chapter and with the backAvard dislocation shown in Fig. 378. 




Fig. 855.— Simple Colles' fracture the result of a fall on the hand. 
a short time following the accident. Appearance typical. 



Picture taken 



presents himself for treatment and relief. The attitude is usually 
characteristic. He stands with the shoulders slightly forward and 
the forearms held horizontally across the body. The injured mem- 
ber is supported by the opposite hand and there is considerable 



FRACTURES OF LOWER END OF RADIUS 



253 




Fig. 356. An example of the radial displacenu'iit of the distal fragment sometimes 
seen in Colles' fracture. Note how the whole hand is displaced to the radial side. 






Fi- 357 




Fig. 358. 

Figs. 357 and 358. — Transverse, impacted Colles' fracture a few minutes following 
fall on hand. This is the type of deformity illustrated in B., Fig. 384. Compare this 
case with the deformity accompanying an oblique Colles' fracture as shown in Figs. 3G6 
and 367. Angular deformity is here present as a result of the impaction, and the direc- 
tion in which the articular surface of the radius looks has been changed. Note the 
prominence on the ventral and ulnar side of the wrist produced by the displaced head of 
the ulna. 



254 



FRACTURES AND DISLOCATIONS 



anxiet}^ in both attitude and gait lest the injured wrist be dis- 
turbed. The onset of swelling about the wrist is prompt and 
sometimes pronounced, and, unless the case is seen immediately 
followino' the accident, the deformity is to some extent masked. 




Fig. 359. — Photograph of a recent Colles' fracture shoAving the change in the con- 
tour of the Avrist resulting from the displacement of the distal fragment. The articular 
surface of the radius looks downAvard and backward instead of downward and slightly 
forward as is normal. Note the curve on the anterior surface of the wrist which is 
less sharp than is seen in a normal wrist in this position. 




361. 



Figs. 360 and 361. — Colles' fracture a few minutes following injury. Prominence 
on ventral surface of forearm is due to distention of the flexor tendon sheaths. 



Loss of function in the hand and wrist is, as a rule, complete, and 
even in instances in which it might be possible for the patient to 
perform some acts with the injured member the pain is usually 
severe enough to inhibit all function. 

The usual silver-fork deformity is characteristic of Colles' frac- 



FRACTURES OF LOWER END OF RADIUS 



255 




Fis:. 361 




Figs. 362 and 363. — Radial and ulnar views of recent Colles' fracture. Line of 
fracture a little higher than usual and dorsal displacement pronounced. 




m-'^'^-m 




Fig. 364. 




Figs. 364 and 365. — Radial and ulnar views of Colles' fracture in old woman a 

few minutes following the accident. Angular deformity and impaction present. Moderate 

displacement of lower fragme];it, Note prominence of ulnar head and displacement of 
hanii to radial side. 



256 



FRACTURES AND DISLOCATIONS 



ture and can best be appreciated by a study of the accompanying 
photographs. No amount of text will convey an idea of the nature 
of this deformity as readily as these illustrations. The radial sty- 
loid is usually raised above its normal level, though in many in- 
stances the displacement is not marked enough to bring the tip 
of the process above the level of the end of the ulnar styloid. 
(See Figs. 376 and 377.) In a transverse Colles' fracture with 




Fig. 366. 




Fig. 367. 

Figs. 366 and 367. — Oblique Colles' fracture a few " minutes following injury. 
Forearm somewhat resembles fracture of both bones of the forearm though palpation 
discloses an intact ulna. The obliquity of the fracture is shown by the deformity. 
Note how low and pronounced the anterior deformity is as compared with the dorsal 
outline. Compare this deformity with the cases of transverse Colles' fracture previously 
shown and examine the accompanying Rontgenograms. X-ray of this case is shown in 
Figs. 346 and 347. 



impaction there is generally rotation and angular deformity as 
well as backward displacement of the lower fragment. Under 
these circumstances it will be noted that the radial side of the 
wrist is displaced further backward than the ulnar side, and that 
the axis of the lower fragment is not parallel with the axis of the 
shaft. Crepitus is easily detected in unimpacted cases. In im- 
pacted cases crepitus will be absent until the impaction has been 



FRACTURES OF LOWER END OF RADIUS 257 

broken up. In more than half of the cases of CoUes' fracture the 
condition is complicated by rupture of the triangular fibro-carti- 
lage or an equivalent avulsion of its ulnar attachment so that the 
head of the ulna and the lower radial fragment are separated and 
the wrist broadened. Fracture of the ulnar styloid, so commonly 
seen in Rontgenograms of CoUes' fracture, is an evidence of the 
action of this ligament. The lower end of the ulna is, as a rule, 
displaced forward as well as inward, and the absence of the 
prominent ulnar head from the dorsum of the wrist is notice- 
able. 

In the usual Colles' fracture the hand is inclined slightly to 
the radial side and the base of the thenar eminence is higher than 
normal. This radial displacement is sometimes pronounced, as 
shown in Figs. 356 and 364. 

In fractures showing extensive comminution of the lower end of 
the radius the deformity is often not characteristic and the condi- 
tion may be compound. When the fracture is produced by an 
auto-crank kick the displacement is often slight and the break is 
usually transverse. A Colles' fracture without deformity is some- 
times seen, though the condition is extremely rare. Even when 
the deformit}^ is slight, it is, as a rule, characteristic. In oblique 
Colles' fractures the ventral deformity is more pronounced and 
lower than in the transverse type. "When the break is oblique the 
plane of the fracture is usually similar to that shown in Fig. 347, 
and the deformity is somewhat different from that seen in trans- 
verse CoUes' fracture. In oblique Colles' fractures impaction, 
crushing of cancellous tissue and comminution are rarely present, 
and the rotary and angular elements in the deformity previously 
described are slight or absent. The lower fragment is displaced 
backward and slightly upward, but the axes of the two fragments 
are parallel, or nearly so, and the direction in which the articular 
surface looks remains unchanged. 

In Barton's fracture the deformity is slightly lower and more 
abrupt than in the typical Colles' fracture. The position of the 
radial styloid remains unchanged and the wrist is not broadened. 
Crepitus is elicited during reduction and it will usually be pos- 
sible to determine that the lower fragment includes only a small 
portion of the lower end and posterior aspect of the radius. In 
the reversed type of Barton's fracture the carpus is displaced for- 
ward instead of backward, and the radial styloid and posterior 



258 



FR.VCTURES AND DISLOCATIONS 



aspect of the lower extremity of the bone are found to be intact 
and undnly prominent when palpated. 

The symptoms of atypical fractures of the lower end of the 
radius vary with the position of the fracture and the direction of 
the displacement. Vertical fractures of the lower end of this 
bone are not accompanied by silver-fork deformity though they 
are almost invariably productive of considerable broadening of the 
wrist. An obliciue fracture passing from the inner border of the 
bone to the articular surface is often quite difficult to recognize 
without the aid of the X-ray. An example of this type of fracture 




Fig. 369. 

Figs. 368 and 369. — Two views of an old epiphyseal separation complicated by frac- 
ture of the posterior aspect of the diaphysis. X-ray of this case shown in Figs. 348 and 
349. Note the Ioav ventral deformity caused by the lower end of the upper fragment 
and the lateral prominence of the lower end of the ulna. Deformity resembles Barton's 
fracture. Case first seen by author six weeks following accident. 



is shown in Fig. 329. In severe crushing injuries of the lower end 
of the radius the condition may be flail-like and quite apparent on 
the most superficial examination. 

The deformity accompanying epiphyseal separations is similar 
to that seen in the ordinary Colles' fracture. It is, however, 
slightly lower and more abrupt in outline and not accompanied 
by true crepitus unless complicated by fracture. Epiphyseal sep- 
arations are often complicated by fracture as shown in Figs. 348 
to 353. When the posterior aspect of the diaphysis is broken off 
and displaced with the epiphysis the deformity closely resembles 



FRACTURES OF LOWER END OF RADIUS 



259 



that seen in oblique Colles' fracture. The dorsal deformity is 
slight while the ventral deformity is pronounced and low. The 
deformity accompanying an uncomplicated epiphyseal separation 
is shown in Fig. 371. 




Fig. 371. Fig-. 372. 

Fig. 371. — Uncomplicated epiphyseal sepaviition of lower end of radius. 
Fig. 372. — Same case immediately following reduction. Forearm partly secured to 
ventral splint. 



260 FRACTURES AND DISLOCATIONS 

Diagnosis. — Colles' fracture is the most common break occurring 
in the lower end of the radius and the symptoms are, as a rule, 
so characteristic that there should be little difficulty in recognizing 
the injury. The history of the case, the typical silver-fork de- 
formity, the elevation of the radial styloid, and the broadening of 
the wrist are symptoms which should be recognized at a glance. In 
typical cases the diagnosis of Colles' fracture is established with- 
out difficulty but the exact nature and position of the break and the 
presence of complicating fractures of the lower end of the ulna or 
of the carpus are often learned only when the wrist is submitted 
to the X-ray. Many of the salient features of the fracture may 
be determined by the nature of the deformity (see ''Symptoms," 
page 252), and the surgeon should gather these data during the 
examination. Prompt reduction is indicated and it is seldom 
advisable to await the returns of an X-ray examination before 
correcting the displacement. It is apparent, therefore, that no 
detail in the physical examination should be slighted which will 
aid in disclosing the nature of the fracture or the character of 
the displacement. When a fracture in this region is suspected the 
surgeon should compare the injured parts with the opposite wrist. 
The transverse diameters of the two wrists should be carefully 
compared. 

The possibility of associated lesions must be kept in mind while 
examining fractures of the lower end of the radius. Fractures 
of both bones of the forearm near the wrist, luxations of the lower 
end of the ulna, dislocations of the wrist and fractures or luxa- 
tions of the carpal bones are conditions which must be differen- 
tiated from fractures of the radius, and recognized as complications 
when they exist. When both bones of the forearm are fractured 
near the wrist, crepitus and abnormal mobility of the ulnar head 
may be detected on manipulation. It is often difficult to recog- 
nize complicating fracture of the ulnar styloid without the aid of 
the X-ray. Dislocations of the wrist are extremely rare and are 
seldom mistaken for Colles' fracture. Colles' fracture, however, 
is not infrequently wrongly diagnosticated as a dislocation. 
There should be no excuse for this mistake if the two deformities 
are compared. (See photographic comparison of the two condi- 
tions as shown in Figs. 378 and 379.) The deformity in disloca- 
tion is much lower and more abrupt in outline and the extensor 
tendons stand out prominently as they pass from the forearm to 



FRACTURES OF LOWER END OF RADIUS 



261 




Fiu'. 87.'). — Yi^ntral view of same case. Note promint 
placement of liand to radial side. 



of ulnar head and dis- 




■»,t*w»- ,*''^.w^--i. 



rig. 376. — Comparing the levels of the two styloids. The radial styloid is raised 
though its tip is still at a lower level than the tip of the ulnar styloid. 




Fig. 377. — Same comparison seen from the dorsal aspect of forearm. 



262 



FRACTURES AND DISLOCATIONS 



the hand. Neither the anterior nor the posterior type of luxation 
of the ulnar head occurs as a complication of Colles' fracture and 
as isolated injuries the symptoms of these two dislocations are 
too characteristic and pronounced to require differentiation. In- 
ward luxation of the ulnar head, however, is a very common com- 
plication of Colles' fracture and is frequently overlooked. Broad- 
ening of the wrist, with inward and forward slumping of the ulnar 
head, is indicative of this complication. On palpation, the lower 
end of the ulna is found less firmly attached to the radius than 
normal. It may be possible to palpate the fractured styloid. It 
is usually not difficult to dift'erentiate fractures and luxations of 




Figs. 378 and 379. — Photographic comparison of Colles' fracture and backward 
dislocation of wrist. The dislocation (lower picture) shows a much more abrupt 
deformity, except where the tendons cross the articulation and the ventral deformity 
is much lower. 

the carpus from Colles' fracture, yet lesions of the carpus accom- 
panying Colles' fracture are not very uncommon and may be 
overlooked. The carpus should be examined for deformit\^ and 
crepitus. If doubt exists after the wrist is thoroughly examined 
it is advisable to resort to the X-ray. Thus the diagnosis is estab- 
lished, the details of the lesion or lesions are disclosed and the 
parts will have been subjected to the least possible manipulation 
and trauma. When, on the other hand, the presence of fracture 
is apparent on examination and the deformity has been imme- 
diately corrected, a Rontgenogram should be made to determine 
the completeness of reduction, to verify the diagnosis and to ex- 
clude associated lesions of adjoining bones. 



FRACTURES OF LOWER END OF RADIUS 



263 



The differentiation of Colles' fracture from simple sprain of the 
wrist is at times more confusing than would at first appear. Swell- 
ing of the parts and distention of the synovial sheaths following 




Figs. 380 and 381. 



Fig. 381. 
-Radial and ulnar views of CoUes' fracture just before reduction. 
(See Figs. 382 and 383.) 




Figs. 382 and 383. — Two methods of grasping the wrist in reducing Colles' fracture. 
The arrows indicate the lines of force employed. 



a sprain may simulate, to some extent, the deformity of Colles' 
fracture. Unless one is familiar with the condition and a careful 
examination is made, a sprain may be mistaken for a fracture, or 



264 



FRACTURES AND DISLOCATIONS 



vice versa. The soft crepitation of a synovitis should not be mis- 
taken for the true crepitus accompanying fracture. Synovial crepi- 
tation is limited to the course of the tendons and is not produced 
by stress on the lower end of the radius. 

Treatment. — Reduction should be effected at the earliest possible 
moment. Tlie sooner the deformity is corrected the less pro- 
nounced will be the subsequent traumatic reaction. Reduction 




A 



B 



f [ M i>ii-»ii te — n^ 



r 




Fig. 384. — Sliows the principles to be followed in reducing the usual transverse 
impacted Colles' fracture. A. Section of normal radius. B. Transverse impacted Col- 
les' of common type. G. shows lower fragment forced back into position. Note wedze- 
shaped space, the result of crushed cancellous tissue. If the fragment is released in 
this position deformity will recur since the posterior layer of compact tissue is not 
engaged. D. shows distal fragment forced forward, thus obtaining an engagement 
which prevents recurrence of deformity. E. represents a form of fracture in which ihe 
posterior cortical layer of the distal fragment is broken up. F. shows the use of pads 
on the splints to maintain reduction when the fracture is of the type shown in E. 



is best accomplished under anesthesia. In many cases a satis- 
factory adjustment of the fragment can be accomplished without 
this aid, yet with the patient unconscious and free from pain the 
surgeon is better enabled to obtain an accurate reposition of the 
fragment. If the fracture is impacted considerable force may be 
needed to free the lower fragment so that it may be replaced. In 
oblique Colles' fracture the lower fragment can, as a rule, be slid 



FRACTURES OF LOWER END OF RADIUS 



265 



back into position but the deformity is likely to recur if the 
fragments are not firmly engaged following reduction. For this 
reason the fractured surfaces should be forced together after the 
fragment has been replaced. When the fracture is transverse and 
there is impaction and crushing of cancellous tissue, reduction 
requires a somewhat different manipulation. In this form of 
fracture the fragments must be separated by traction and counter- 
traction to pull the low^er end of the upper fragment out of the 
lower fragment. AVhen this has been accomplished the lower frag- 
ment is pulled downward and forward and the deformity slightly 
over-corrected. In this way the layer of compact tissue on the 









Ih^Vla-i' 


5fii>ytK 


Fig. 385. 


3(n<icil 


^f,luH.V 





Fig. 386. 

Figs. 385 and 386. — Diagrams of splints used in the treatment of fracture's of 
the forearm. The ventral splint is cut out to avoid pressure on the thenar eminence. 
(See Figs. 307 to 312.) 






Fig. 387.^— Shows a dorsal splint, cut-out opposite the head of the ulna. 
rarely needed if a heavy enough layer of padding is used. 



This is 



posterior surface of the low^er fragment is engaged against the 
corresponding layer in the upper fragment and redisplacement is 
prevented. If this is not accomplished the deformity will recur 
since the lower end of the upper fragment wdll drop back into the 
space in the lower fragment corresponding to the crushed cancel- 
lous tissue. The accompanying diagrams (Fig. 384) illustrate the 
manner in which deformity recurs and the necessitj^ for slightly 
over-correcting the displacement. Manipulations such as shown in 
Figs. 382 and 383 are recommended in correcting the displacement 
but the most important requisite for proper reduction is a clear 
understanding on the part of the surgeon concerning the nature 
of the break and the relative positions of the fragments. 

The grip shown in Fig. 383 usually works well in the oblique 
type of Colles' fracture while the one shown in Fig. 382 is most 



266 



FRACTURES AND DISLOCATIONS 



efficient when the break is transverse and impaction exists. If the 
lower radio-uhiar articulation remains intact reduction can some- 
times be effected by strong ulnar flexion of the wrist. By this 
method the radio-ulnar articulation is used as a fulcrum in forcing 
the lower radial fragment back into position. Care should be 
exercised, however, not to place more strain on the articulation 
than it will stand as otherwise it may be broken up, thus increasing 
the damage instead of correcting the deformity. After the dis- 
placement of the radial fracture has been corrected lateral pressure 
should be exerted on the lower end of the ulna to force the ulnar 
head home against the sigmoid cavity of the radius; thus correct- 
ing the lateral and forward displacement of the ulna. 




Fig. 388. — The Walker splint, 
the treatment of Colles' fracture. 



Made in "rights"' and "lefts" and in five sizes for 



Numerous splints have been devised to prevent recurrence of 
deformity and they are of some advantage, though their value 
has been greatly exaggerated. Special padding and splints of 
special design should never be used with the idea of actively cor- 
recting deformity. The displacement should be overcome as fully 
as possible at the time of reduction and the most that should be 
attempted in fixation of the parts is to prevent the recurrence of 
the deformity. The various types of dressing which have been 
employed in the fixation of Colles' fracture are too numerous to 
mention. The most important element in the treatment of these 
cases is to secure an accurate reduction and firm engagement of 
the fragments, and to then protect the parts from strains which 



FRACTURES OF LOWER END OF RADIUS 267 

might disturb the fragments. The nature of the fixation employed 
will depend on the tendency to recurrence of deformity and the 
age and temperament of the patient. An adult may in most cases 
be depended upon to avoid disturbing the parts during the after- 
treatment and to follow the instructions given by the surgeon. 
On the other hand an active child cannot be trusted and the wrist 
should be so firmly dressed that the parts are not likely to be 
accidentally disturbed. 

AYhen therefore a solid engagement can be obtained in a depend- 
able adult the wrist may be encircled with a strip of adhesive 
plaster and the forearm carried in a sling. The hand should not 
be supported by the sling but is allowed to hang dependent from 




Fig. 390. Fig. 391. 



Fig. 389. — Short splints applied to wrist and held in position by circular strap of 
adhesive. 

Fig. 390. — Shows proper position of wrist and hand. Wrist is carried in ulnar 
flexion. 

Fig. 391. — ^Shows improper method of carrying wrist and hand. Forearm pronated 
and wrist flexed. 

the wrist in a position of ulnar flexion. Excellent results can be 
obtained in this way, provided a solid engagement of the fragments 
has been secured and the patient follows directions and does not 
disturb the parts. If a short, properly padded dorsal splint is 
secured in position with a circular strip of adhesive plaster the 
immobilization will be found more secure than that obtained by 
the encircling strip of adhesive alone. When the short dorsal 
splint is employed appropriate padding should be placed between 
the adhesive and the ventral surface of the wrist. In instances in 
which there has been much comminution and the tendency to recur- 
rence of deformity cannot be overcome during reduction this 
method is entirely too insecure and should not be employed. Under 



268 FRACTURES AND DISLOCATIONS 

these circumstances the anterior and posterior splints snch as used 
in the treatment of fractures of the forearm will, in most cases, 
serve the purpose better. Heavy padding of the posterior splint 
below the plane of fracture and of the anterior splint above the 
break will tend to prevent the return of the silver-fork deformity. 
The best material for this special padding is saddler's felt which 
may be obtained from any harness shop. It is elastic, holds its 
shape well and may be cut into pads of desired proportions. The 
splints should be a little broader than the forearm in its thickest 
part and should be loosely enough applied to avoid constriction. 
The forearm should not be bandaged before the splints are placed 
in position. The padding is never used with the expectation of 
actively forcing the fragments back into place but only for the 
purpose of preventing redisplacement. One splint, usually the 
anterior, is secured in place by strips of adhesive. The opposite 
splint is then applied and may be removed separately during the 
after-treatment without depriving the fracture of the support 
offered by the opposite splint. (See Figs. 307 to 312.) In this 
way the anterior splint supports the forearm and wrist while the 
surgeon is inspecting the parts and readjusting the dressing. 
It is of paramount importance that free circulation be present after 
the dressings are in place. During the first few days following 
the injury due allowance should be made for the swelling which 
comes with traumatic reaction. Constriction may be readily de- 
tected by examining the nails. The dangers of too tight bandaging 
and strangulation of the forearm have already been mentioned 
under ''Fractures of Bones of the Forearm." The Bond splint 
and others of the same type which maintain the wrist in a position 
of ulnar flexion are of service in some cases but their value has 
been greatly overestimated. It has been customary for years to 
consider the position of the hand as exerting great influence on the 
recurrence of deformity. As a matter of fact there are a few 
conditions in which the position of the hand affects the position of 
the fragment, but in nearly all fractures in this region the prime 
requisite in avoiding the recurrence of deformity is the proper 
reduction of the deformity and firm engagement of the fragments. 
If the lower radio-ulnar articulation remains intact ulnar flexion 
will tend to hold the lower radial fragment in reduction, but if 
the articulation has been broken up, this position will only increase 
the displacement of the ulnar head. Comminution of the lower 



FRACTURES OF LOWER END OF RADIUS 269 

end of the radius, crushing of the cancellous tissue in this region 
and obliquity in the plane of fracture are the most common causes 
of recurrence of deformity following proper reduction, and the 
position of the hand during the after-treatment has little influence 
in maintaining reduction when these conditions exist. Flexion of 
the wrist places the extensor tendons on the stretch and they are 
thus supposed to exert a splinting action on the fragments. 
Ulnar flexion throws more strain on the ulna and relieves the 
radius, to some extent, of the shortening effect of the muscles of 
the forearm. It is questionable, however, if either of these posi- 
tions makes enough difference to be of practical importance in the 
treatment of Colles' fracture. Extensive comminution of the lower 
end of the radius renders the fragments difficult to maintain in 
good reduction and it is here that ulnar flexion will be found of 
most value, provided the lower radio-ulnar articulation has not 
been broken up. 

The reduction of Barton's fracture involves the same principles 
as already described in correcting the deformity of Colles' frac- 
ture. In atypical fractures of the lower end of the radius the 
surgeon must be guided by the nature of the fracture and the 
character of the displacement. If the type of the fracture is 
fully appreciated the surgeon will be better able to correct the 
deformity and hence the value of the X-ray, especially in instances 
in which difficulty is experienced in correcting the displacement. 
Occasionally cases are encountered in which reduction cannot be 
accomplished without resorting to open incision. The local use of 
the ice bag during the first twenty-four to forty-eight hours will 
be found of great service in controlling the traumatic reaction, 
especially in cases in which the causative trauma has been severe. 

Operative Treatment. — Operation is sometimes indicated when 
a satisfactory reduction cannot be otherwise obtained. A small 
fragment of bone may become interposed between the fractured 
surfaces and require removal before the deformity can be cor- 
rected. Direct reposition of the fragments through the incision 
will be all that is required in most cases. 

The common fracture of the lower end of the radius is best ap- 
proached through a longitudinal incision on the outer side of the 
wrist. This incision exposes the radial artery and nerve and 
the extensors of the thumb. Under cover of the posterior lip of 
the wound will be found the radial extensors of the carpus. The 



270 



FRACTURES AND DISLOCATIONS 



course of the radial artery is sometimes anomalous, winding around 
the lower fourth of the radius instead of passing through the ana- 
tomical snuff-box. This condition may be recognized by palpating 
the artery even before the incision is made. Oblique Colles' frac- 
ture and some of the atypical breaks seen in the lower end of the 
radius may need some form of internal fixation to prevent recur- 
rence of deformity. The placing of this material will depend en- 
tirely on the nature of the fracture and the character of the 
displacement. In oblique fractures which cannot otherwise be 




392. 



Fig. 393. 



Fig. 392. — Skiagram showing radial epiphysis displaced to the radial side and a 
portion of the shaft of the bone carried with it. (Haubold — Journal A. M. A.) 

Fig. 393. — Skiagram showing the detached fragment nailed to the shaft of the 
bone. (Haubold — Journal A. M. A.) 



maintained in reduction a small loop of wire passing through the 
fragments will often accomplish all that is desired. In instances 
of pronounced radial displacement of the lower fragment a satis- 
factory fixation may be obtained in some cases by nailing the lower 
fragment to the upper as shown in Fig. 393. Epiphyseal 
separations seldom require operative intervention. Occasionally an 
untorn periosteum may offer resistance to the reduction of a dis- 
placed epiphysis and it may be necessary to divide this tissue be- 
fore the deformity can be corrected. Recurrence of deformity in 
an epiphyseal separation may be due to a complicating fracture of 



FRACTURES OF LOWER END OP RADIUS 271 

the diaphysis (see Fig. 349) and to prevent this tendency to dis- 
placement it may be necessary to wire the fragments of the di- 
aphysis together. 

Compound fractures of the lower end of the radius should be 
treated according to the principles as laid down under the heading 
of ''Treatment of Compound Fractures and Dislocations," page 
789. 

In some cases of comminution of the lower end of the bone a 
circular wire will so bind the fragments together that the com- 
minuted bony area is brought closer together and the deformity 
lessened. In other cases the comminution may be so extensive that 
operative procedure is not advisable. 

Old cases of Colles' fracture with deformity and pronounced loss 
of function may require operation for the correction of the de- 
formity and the breaking up of adhesions. This operation, how- 
ever, should not be undertaken without a careful study of the case 
including an X-ray examination. One should determine, as far as 
possible, how much of the loss of function is due to the deformity, 
and how much is the result of joint and tendon adhesions, and 
whether or not there is a rarifying osteitis of the lower end of 
the radius. The loss of function is more often due to adhesions 
than to deformity, and hence the greatest good will, in most cases, 
result from a breaking up of these adhesions under anesthesia, 
without incision of the parts or refracture of the bone. Kecent 
cases may be refractured without incision, provided the condition 
is not more than three or four weeks old. It is usually best, how- 
ever, to produce refracture through an incision since more accurate 
work can be done in this way. 

After-Treatment. — The case should be seen daily for the first few 
days to adjust the dressings to the varying size of the forearm 
and wrist during the onset and subsidence of traumatic swelling. 
Eecurrence of deformity should be watched for and corrected if 
it occurs. Disturbance of the circulation or pain (especially in the 
region of the three pressure points) calls for readjustment of the 
dressings and inspection of the region of fracture. The three 
pressure points just referred to are the head of the ulna, the bases 
of the second and third metacarpals and the thenar eminence. 
Undue pressure at these points may lead to sloughing of the soft 
tissues which is a painful, annoying and serious complication. The 
lower end of the anterior splint should be cut away on the radial 



272 FRACTURES AND DISLOCATIONS 

side to avoid pressure on the thenar eminence as already described 
in the treatment of ''Fractures of the Radial and Ulnar Shafts" 
on page 224. The posterior splint should be well padded oppo- 
site the hand and wrist to avoid undue pressure on the head of the 
ulna and the bases of the metacarpals. If unusual difficulty is 
experienced in avoiding pressure on these points the posterior splint 
may have holes drilled through it corresponding to these promi- 
nences and the padding reapplied. Pain should not be pronounced 
after six or eight hours. The fingers must be moved daily during 
the entire course of the treatment. Immobilization of the fingers 
is followed by a loss of function which is probably worse than the 
sum total of untoward symptoms seen in untreated cases. It is 
much more important to secure a good functional result than it 
is to have the fragments in perfect anatomical relation, and it must 




Fig. 394. — CoUes' fracture about twenty-four hours following accident. Displace- 
ment of fragment slight but traumatic reaction pronounced. Swelling masks deformity 
to gi'eat extent. It is during the first twenty-four or forty-eight hours that there is 
danger of the circulation being interfered with as a result of the forearm swelling within 
the dressings. It is therefore imperative that the first dressings be loosely applied 
and the member closelv watched for signs of strangulation. (See Figs. 318,' 319 and 
320.) 

not be forgotten that function depends more on the earlj^ and free 
passive motion of the fingers and thumb during treatment than on 
anything else. The older the patient the more important is pas- 
sive motion. At the end of a week or ten days the posterior splint 
may be dispensed with, and both may be discarded, in the average 
case, two weeks from the time of accident. A strip of adhesive 
may then be placed about the wrist and the forearm carried in a 
sling with the hand hanging dependent in a position of ulnar 
flexion. In some cases the posterior splint may be retained for a 
we^k or ten days longer as a precaution against external violence. 
This is particularly advisable in the treatment of children. Old 
patients should be allowed more time for union to take place. Un- 



FRACTURES OF LOWER END OF RADIUS 



273 



necessary strain to the wrist should be avoided for a month or 
more following removal of dressings, but the patient should be 
urged to use wrist and fingers freely so that function may be fully 
restored. In favorable cases gentle passive motion of the wrist 
should be begun as early as the end of a week or ten days follow- 
ing injury and kept up daily until union is present and function 
restored. Hot water and massage are of service in restoring the 
parts to normal free function and should be persisted in until 
recovery is complete. The after-treatment of atypical fractures 
and epiphyseal separations of the lower end of the radius involves 
the same principles as already given in the after-care of a typical 
CoUes' fracture. 

Prognosis. — Bony union is well established at the end of three 
weeks in the healthy young adult. Complete supination will usu- 




Fig. 395. 




Fig. 396. 

Figs. 395 and 396. — Characteristic deformity following incomplete reduction of an 
oblique Colles' fracture. Note slight silver-fork deformity and transverse thickenins: 
of the wrist which results from rupture of the lower radio-ulnar ligament of fracture 
of ulnar styloid. Lateral and ventral slumping of lower end of ulna apparent. Case 
first seen by author at time this photograph was taken. 



ally be the last motion to be fully restored; this is particularly 
true in instances in which the lower radio-ulnar articulation has 



274 



FRACTURES AND DISLOCATIONS 




Fig. 397. — Another case of broadened wrist following incomplete reduction of 
Colles' fracture. Patient presents himself for treatment because of slow recovery and 
inability to use hand. Wrist stiff, painful, etc. Case first seen by author at time this 
photograph was taken. 




Fig. 398. — Another case of slow and incomplete recovery following Colles' fracture. 
In this case the reduction has been excellent but the after-treatment has been faulty 
in that the patient's hand, wrist and fingers were completely immobilized for a period 
of six weeks. Adhesions between the joint surfaces and within the tendon sheaths have 
resulted and the X-ray discloses an osteitis of the carpus. Patient 55 years of age. 
(See Pig. 899.) Case first seen by author at the time this picture was taken. 






f 



Fig. 399. — Osteitis of the carpus and bases of the metacarpals following a Colles' 
fracture in which the condition was treated by prolonged immobilization. This condi- 
tion is not uncommon in patients past middle life in which the parts are immobilized 
for too long a period. A condition such as this is very much easier to avoid than it is 
to treat, after it has become established. It should be remembered that the possibility 
of fracture in breaking up adhesions is greater in a case like this than it would be if the 
carpal bones were normal. 



FRACTURES OF LOWER END OF RADIUS 



275 



been broken up or in cases in which the fracture has entered the 
sigmoid cavity of the radius. In older persons restoration of func- 
tion is much slower and adhesions in and about the tendon sheaths 
and in the wrist joint are more prone to occur and are important 
elements in restricting motion. The complete restoration of func- 





Fig. 401. 

Figs. 400 and 401. — Contracture of the hand following Colles' fracture. Nerves 
injured either at the time of the accident or during the after-treatment from too tight 
bandaging. Indication of beginning contracture first noted at the time the splints were 
removed. First seen by author about eighteen months after the injury. 



tion depends more on the early and persistent use of passive mo- 
tion than on the anatomical reduction of the displacement. The 
prognosis, therefore, is more or less directly dependent on the 
proper use of passive motion during the after-treatment. In some 
cases joint and tendon adhesions and rarifying osteitis develop in 
spite of the most careful treatment (see Fig. 399) but these con- 



276 FRACTURES AND DISLOCATIONS 

ditions are fortunately rare in cases receiving the proper care dur- 
ing the after-treatment. Restricted motion of the wrist and 
fingers, and slight pain especially in the region of the ulnar styloid, 
are conditions which may persist for months but will, as a rule, 
pass off Avith massage and hot applications. The more faithfully 
passive motion is carried out during the time the wrist is immobi- 
lized the less pronounced will be these annoying sequelae. Destruc- 
tion of bony tissue in the lower end of the radius, such as occurs 
in impaction and extensive comminution, may render accurate re- 
duction, even under operation, impossible and hence some deformity 
will result, but this does not necessarily mean any considerable loss 
of function. 

An ordinary uncomplicated Colles' fracture which is properly 
reduced and treated should be followed, in a healthy adult, by 
complete restoration of function. In older patients a perfect func- 
tional result will be more difficult to obtain. In atypical fractures 
of the lower end of the radius the prognosis will vary with the 
severity and character of the fracture. Uncomplicated epiphyseal 
separations of the lower end of the radius should be followed by 
perfect results both functionally and anatomically if the epiphysis 
is properly reduced. Disturbances in the growth of the radius 
are rarely seen following epiphyseal separations, if anything like 
a perfect reduction has been obtained. Even in cases in which 
pronounced displacement is allowed to persist defective growth is 
rarelv seen. 



CHAPTER XX. 

INJURIES TO THE CARPUS. 

Under this heading is included: radio-carpal luxations (com- 
monly spoken of as dislocations of the wrist), medio-carpal luxa- 
tions, and fractures and dislocations of the individual carpal bones. 

Surgical Anatomy. — The strength of the wrist is such that when 
subjected to violence fracture is more likely to occur above or 




Fig. 402 



Figs. 402 and 403. — Ventral and dorsal vieAVS of ligaments of hand. U., ulna; R., 
radius; U.N., uncinate; P., pisiform; T., trapezium. 

below this region than in the carpus itself. The ligaments bind- 
ing the bones of the forearm to the carpus, those between the 

277 



278 



FRACTURES AND DISLOCATIONS 



carpus and metacarpus, and the inter-carpal ligaments are all 
heavy and strong but the main strength of the wrist is dependent 
on the numerous and heavy tendons which pass from the forearm 
to the hand, and are bound firmly to the bones by the annular 
ligaments and the fibrous compartments through which they run. 
It should be remembered that though the carpus is actuated by 
the flexors and extensors passing from the forearm to the hand, 
only one of these muscles is inserted into the carpus. The flexor 
carpi ulnaris is inserted into the pisiform but since this bone is 




Fig. 404. — Bones of normal wrist. 1 M, 2 M, 3 M, 4 M, and 5 M indicate meta- 
carpals; Tm., Trapezium; Td.. Trapezoid; O.M., Os Magnum; TJ., Unciform; C, Cunei- 
form; P., Pisiform; SI., Semilunar; Sc, Scaphoid'; JJl., Ulna; R., Radius. 



functionally a sesamoid bone and not truly a bone of the carpus 
we may consider the carpus as free from the insertions of the 
muscles of the forearm. Thus the carpus is actuated indirectly 
through the metacarpal bones. Some of the intrinsic muscles of 
the hand arise from the ventral surface of the lower row of carpal 
bones, but their action is on the metacarpus rather than the carpus. 
The radio-carpal or tvrist joint is a condyloid articulation. The 
articular surface of the lower end of the radius and the inferior 
surface of the triangular fibro-cartilage form the socket, while the 
upper surfaces of the scaphoid, semilunar and cuneiform bones 



INJUEIES TO THE CARPUS 



279 



form tlie condyle. Motion of this articulation is possible in every 
direction except axial rotation. The plane of the radio-carpal 
joint is on a level with the tip of the ulnar styloid. Luxations of 
this joint may take place in any direction but are extremely rare; 




Pig. 405. 



Fig. 406. 



Fig. 405. — Old CoUes' fracture. Triangulare present. Indicated by arrow. 
Fig. 406. — Anottier old Colles' fracture with anomalous triangulare. 




Fig. 40 7. 



Fi^ 



Fig. 407. — Example of anomalous centrale. 

Fig. 403. — Space in carpus corresponding to site of centrale. Anomalous condition 
present though the embryonic elements entering into formation of central© show no 
signs of ossification. 

only a few cases of each type having been recorded. Colles' frac- 
ture is frequently mistaken for dislocation of the wrist, and the 
cases of this luxation reported prior to the advent of the X-ray 
are particularly untrustworthy. Dislocation of the wrist compli- 
cated by fracture of the lower end of the radius is not nearly as 



280 



FRACTURES AND DISLOCATIONS 



uncommon as the pure luxation. When the carpus is displaced 
backward and upward and the posterior lip of the radius is broken 
off and displaced with the carpus, the condition is known as Bar- 
ton's fracture and has been described under "Fractures of the 
Lower End of the Radius." AAHien the reverse condition obtains, 
that is, when the ventral lip of the radius is broken off and dis- 




Fig. 409. — Old united fracture of scaphoid. 




Fig. 410. — Fracture of semilunar. 



Fig. 411. — Fracture of scaphoid. 



placed forward and upward with the carpus, it is known as a 
"reversed Barton's fracture." Lateral luxations of this joint, 
either with or without fracture, are too rare to be considered as a 
type. It is probable that a large proportion of the reported cases 
of luxation of the radio-carpal joint (especially those not examined 
with the X-ray) have in reality been Colles' fractures or at least 
fracture-luxations of Barton's type. 



INJURIES TO THE CARPUS 



281 




Fig. 412. — Fractured cuneiform. 




Fig. 413. Fig. 414. 

Figs. 413 and 414. — Anteroposterior and lateral views of luxated semilunai 



282 



FRACTURES AXD DISLOCATIOXS 



Luxations of the rnedio-carpal arficulo.fio/i probably never occur 
as a pure dislocation, following accurately the lines of the medio- 
carpal articulation. They are usually complicated by fracture of 
one or more of the carpal bones with displacement of the fragments. 

Isolated fractures and luxations of the carpal bones are not 
Tery uncommon injuries and are now known to accompany frac- 
tures of the lower end of the forearm more frequently than was 
stipposed prior to the establishment of the Kontgen ray as a diag- 
nostic measure. 




Fi^. 415. 



Fi^. 416. 



Figs. 415 and 416. — Old Colles' fracture showing un-united fracture of ulnai 
styloid and an abnormal condition in the scaphoid. Either an old fracture or s 
"divided scaphoid." 



A study of the X-ray records of these injuries has brought up 
a most important and confusing subject; namely, the anomalies 
of the carpal bones. The development of the carpus shows con- 
siderable variation and anomalies of the bones of the carpus are 
comparatively of freciuent occurrence. It will be impracticable, 
here, to enter into all the possible variations : the reader is referred 
to the most excellent and thorough work done by Thomas Dwight, 
as set forth in his book on '"Variations of the Bones of the Hand 
and Foot." Occasion will be taken, however., to call attention to 
some, of the more common anomalies which are, at times, con- 



INJURIES TO THE CARPUS 



283 



founded with fracture. Anomalies may consist of supernumerary 
bones, due either to the persistence of embryonic elements or to 
the division of one or more of the carpal bones. Another form of 
anomaly is seen in instances in which two or more of the carpal 
bones are fused, or in which fusion has taken place between an 
accessory bone and one of the bones of the carpus. These anoma- 
lies of fusion are of anatomic interest only, since there is no 
occasion for mistaking them for fractures as is the case when super- 




Fig. 417. — "Divided scaphoid," 

numerary bones are present or when one of the bones of the carpus 
is divided. 

The following anomalies are described in detail by Dwight, and 
from a surgical standpoint are the most important occurring in 
the carpus. 

The scaphoid is not uncommonly divided, either partially or com- 
pletely, into two lateral portions. An example of this condition 
is shown in Fig. 417. This anomaly resembles fracture of the 
scaphoid. 



284 



FRACTURES AND DISLOCATIONS 




Fig. 418. — Centrale present and fused with os magnum. 




Fig. 419. — Fractured trapezium indicated by upper arrow. Colles' fracture 
dicated by lower arrow. 



INJURIES TO THE CARPUS 285 

The semilunar sometimes gives the appearance of being divided 
into a palmar and a dorsal portion, but this is probably due to an 
accessory bone to be spoken of later (the epilunatum). 

The cuneiform varies considerably in both size and form but sel- 
dom presents any anomaly which might be mistaken for fracture. 

The pisiform may show some variations in size and shape ; there 
may be an accessory pisiform. 

The hamular process of the unciform may be separate from the 
body of the bone and the line of division may be mistaken for a 
fracture. 

The epilunatum and liypolunatum are two accessory bones which 
(when present) are situated at the tips of the crescentic-shaped 
semilunar. The dorsal anomaly (the epilunatum) is more fre- 
quent and usually of larger size than the hypolunatum which 
occurs opposite the ventral horn of the semilunar. The epilunatum 
is sometimes well developed while the semilunar is correspondingly 
smaller than usual. This condition gives the appearance of a di- 
vided semilunar and may be mistaken for fracture. 

The styloid process of the middle metacarpal is sometimes free 
and appears as a supernumerary bone in the carpus. 

The centrals is a supernumerary ossicle sometimes seen between 
the OS magnum, scaphoid and trapezoid. An example of this con- 
dition is shown in Fig. 407. Fig. 408 shows the same condition 
except that the anomalous structure has never ossified, though the 
space for its accommodation persists. 

Fig. 405 shows an example of the triangulare which may be mis- 
taken for a fractured ulnar styloid. 

The radiale externum is an accessory bone situated on the radial 
side of the scaphoid and is said to be the separated tubercle of the 
scaphoid. 

The ulnar e externum is an accessory ossicle on the ulnar side of 
the carpus internal to the cuneiform. 

The subcapitatum is an accessory ossicle situated at the base of 
the OS magnum. It is said to represent the detached base of this 
bone. 

Numerous variations may occur in the carpus which have not 
been mentioned but those cited above are the ones most likeh^ to 
be confused with fractures in this region. The recognition of these 
anomalies and their differentiation from fractures of the carpus 
will be considered later under Diagnosis. 



286 FRACTURES AND DISLOCATIONS 

The bones of the wrist begin to ossify in the following order: 
the OS magnum and the unciform during the first year, the cunei- 
form during the third year, the semilunar and trapezium during 
the fifth year, the scaphoid during the sixth and the trapezoid 
during the eighth year. The pisiform begins to ossify anywhere 
from the eighth to the twelfth year. 

The scaphoid is occasionally broken as a result of forces similar 
to those producing Colles' fracture. The line of fracture is usu- 
ally across the middle of the bone as shown in Fig. 411. This 
fracture is not an uncommon complication of fractures of the 
lower end of the radius. A fragment of the scaphoid may be dis- 
placed or luxation of the entire bone may accompany fracture of 
the lower end of the radius or some of the other bones of the 
carpus. The few reported cases of uncomplicated luxation of the 
scaphoid have been of the backward type and were probably due 
to forced flexion of the wrist. Forward luxations seem to be in- 
variably complicated by some other lesion, such as fracture of the 
lower end of the radius. 

The semilunar is rarely fractured as an isolated injury. Luxa- 
tion of this bone, however, is not uncommon and may be accom- 
panied by fracture of the scaphoid or other lesions in the adjoining 
carpal bones or in the radius. The displacement in luxations is 
almost invariably forward, the bone apparently being driven from 
its position among the other carpal bones by forced dorsal flexion 
of the wrist. 

The cuneiform is rarely injured except in general crushes of the 
carpus. 

The unciform is rarely injured except as the result of direct 
violence, though a few cases of isolated luxation have been reported. 

Both fracture and luxation are occasionally seen in the os mag- 
num though the latter condition is almost always partial, or more 
properly a subluxation. The displacement is backward and the 
result of forced flexion of the wrist. Chronic subluxations of the 
head of the os magnum may result from heavy manual labor, espe- 
cially in children. 

Both fractures and luxations of the trapezium and trapezoid are 
exceptionally rare as isolated injuries. 

The pisiform is known to have been broken through the action of 
the attached flexor carpi ulnaris and luxation of this bone has been 
reported a number of times. The pisiform is sometimes broken as 



INJURIES TO THE CARPUS 



287 



a result of direct violence. The position of this bone is more ex- 
posed than other bones of the carpns. The displacing action of 
the flexor carpi nlnaris may separate the fragments. Rupture of 
the piso-metaearpal and piso-uncinate (the equivalents of the ten- 
don below the bone) may result in an upward luxation of the 
pisiform. 

In crushing injuries of the carpus any or all of the bones may 
be injured, depending on the nature and severity of the trauma. 

Symptoms. — The symptoms accompanying fractures and luxa- 
tions of the carpus depend on the nature of the injury and the 
position of the resultant lesion or lesions. 

In dislocations of the wrist (radio-carpal joint) the carpus is 
usually displaced backward. The deformity is low and abrupt in 




Fig. 42U. — Se\ti-f eoHipo'iind fracture dislocation of wrist sustained in railroad 
accident. Skin is the only tissue connecting forearm and hand. Rubber tourniquet 
seen in position having been applied to control hemorrhage immediately following acci- 
dent. Picture taken just prior to amputating. 



outline and the extensor tendons stand out prominently as they 
pass from the dorsum of the forearm to the back of the hand. 
The clinical appearance of this deformity is well shown in Fig. 
379. Palpation of the lower end of the radius will show that this 
bone is intact if the condition is a pure luxation. Pain and loss 
of function accompany the injury and are pronounced. Swelling 



288 FRACTURES AND DISLOCATIONS 

develops rapidly and if the case is not seen soon after the accident 
the deformity is to some extent obscured. If this luxation is com- 
plicated by fracture of the lower end of the radius crepitus will 
be present and there is likely to be a tendency to recurrence of 
deformity following reduction. In the anterior form of luxation 
the deformity is of the gardener 's-spade type and resembles the 
displacement seen in reversed Colles' fracture. The deformity, 
however, is lower and more abrupt in outline and the posterior lip 
of the lower end of the radius stands out prominently. Since this 
luxation is frequently complicated by fracture of the lower end of 
the radius crepitus may be present. 

The symptoms accompanying mecUo-carpal luxations closely re- 
semble those of dislocation of the radio-carpal articulation. The 




Fig. 421. — Slight deformity folloAving compound cmishing injury of the lower end 
of ulna and radius and the ulnar side of carpus. Wrist was caught in large gears. 
Picture taken some years after recovery. 

deformity, however, is slightly lower and it may be possible to pal- 
pate the proximal row of carpal bones in their normal relations 
with the radius. Since this luxation is practically always compli- 
cated by fracture of the carpal bones or of the lower end of the 
radius crepitus is to be expected. The luxation may be either for- 
ward or backward and accordingly the deformity may be either of 
the silver-fork or gardener 's-spade variety. 

The s3^mptoms accompanying isolated fractures and luxations of 
the carpal bones are indistinct and not characteristic as compared 
with other lesions in this region. This will be found particularly 
true in cases in which swelling is pronounced. The following symp- 
toms, however, are more or less peculiar to lesions of the different 
bones. 



INJURIES TO THE CARPUS 289 

Fracture of the scaplioid is usually accompanied by local tender- 
ness in the ' ' anatomical snuff box. ' ' The hand may be slightly ab- 
ducted and the vertical depth of the radial side of the carpus may 
be somewhat diminished if the scaphoid has been crushed or com- 
pletely luxated. It may be possible to elicit crepitus and in some 
cases it may be accurately enough located to be recognized as ema- 
nating from the scaphoid. Isolated luxation of the scaphoid is a 
rare condition and the symptoms vary, according to the direction 
of the dislocation, whether or not the scaphoid is fractured as well 
as luxated and the completeness of the displacement. Palpation 
at the back of the wrist may reveal the absence of the scaphoid 
from its normal position if the luxation is ventral, or on the other 
hand, there may be an abnormal prominence on the dorsal aspect 
of the carpus if the luxation is backward. Crepitus may be pres- 
ent if fracture complicates the luxation. 

The symptoms accompanying fracture of the semilunar are simi- 
lar to those of fracture of the scaphoid. Fracture of the semi- 
lunar, however, rarely occurs as an isolated injury, and when 
crepitus is detected in this region of the carpus it is fair to pre- 
sume that the lesion is situated in the scaphoid rather than in the 
semilunar. In forward luxations of the semilunar the displaced 
bone may be palpated on the ventral aspect of the wrist. In back- 
ward luxations it may be recognized as a hard prominence just 
below the radius and at about the middle of the carpus. 

Fracture of the cuneiform is practically unknown except as a 
part of extensive injuries in which the carpus is crushed. The 
author knows of no case of isolated luxation of this bone. The 
symptoms to be expected, however, would resemble those accom- 
panying fracture and luxation of the scaphoid and semilunar. 

Fracture of the pisiform is not necessarily accompanied by char- 
acteristic symptoms even though the bone is more superficial than 
other bones of the carpus. The displacing action of the attached 
muscle may so separate the fragments that crepitus cannot be ob- 
tained. Pain on use of the wrist and local tenderness may be the 
only symptoms. In upward luxations of this bone it may be pos- 
sible to recognize the altered position. 

Fracture of the os magnum is accompanied by pain and tender- 
ness in the center of the carpus, more or less loss of function and 
crepitus when the carpus is properly manipulated and palpated. 
The condition, however, is rare and easily confused with other 



290 FRACTURES AND DISLOCATIONS 

fractures in this region. Luxation of this bone is quite rare. A 
number of cases of subluxation of the head of the os magnum have 
been reported. They have been accompanied by an undue promi- 
nence on the dorsal aspect of the carpus, especially during com- 
plete dorsal flexion of the wrist. The loss of function produced 
by these subluxations is surprisingly slight. 

Fractures of the trapezium and trapezoid are extremely rare 
except in severe crushes of this region. They may occur, however, 
and are accompanied by crepitus and mobility at the base of the 
first or second metacarpal, as the case may be. Crepitus in the 
region of the base of the first metacarpal is almost always caused 
by Bennett's fracture and rarely by fracture of -the trapezium (see 
''Fractures of the Metacarpals," page 297) . Luxations of either of 
these bones is extremely rare, and since only dorsal luxations have 
been reported, the prominence of the displaced bone may be ex- 
pected on the dorsal aspect of the carpus. 

Fracture of the unciform is practically unknown except as a 
complication of luxation or in severe crushing injuries of the 
carpus. The process has been reported as broken off accompanying 
luxation. 

Diagnosis. — Theoretically the diagnosis of fractures and luxa- 
tions of these bones should be easy but the difficulty of ascertaining 
the exact nature of these injuries is shown by the frequency with 
which the diagnosis is changed after the X-ray has been employed. 
The appearance of the wrist is so characteristic in luxations of the 
radio-ulnar joint that it would seem almost impossible to fail in 
recognizing the nature of the injury. It is a well known fact, 
however, that Colles' fracture is frequently mistaken for disloca- 
tion of the wrist. One who has never seen a dislocated wrist 
should hesitate in pronouncing an injury of this region a dislo- 
cation unles the diagnosis has been confirmed by an X-ray ex- 
amination. (See Figs. 378 and 379.) Medio-carpal luxations are 
extremely rare and it will be safer to make only a tentative diag- 
nosis pending the report on the X-ray, even though one feel reason- 
ably certain of the condition. 

The size of the carpal bones and their compact arrangement are 
such that accurate diagnoses of isolated lesions of these bones are 
almost impossible. The important point to be determined by in- 
spection and palpation is whether or not fracture or luxation 
exists. The treatment of the different traumatic lesions in this 



INJURIES TO THE CARPUS 291 

region is similar, and the details of the damage done may be 
learned by resorting to the X-ray. The carpus is most satisfac- 
torily palpated by flexing the wrist. This position exposes the 
dorsal surfaces of the carpal bones and palpation will then reveal 
any abnormal prominence or depression. Slight passive motion 
while palpating the carpus in this way will usually elicit crepitus 
in the presence of fracture. One should not fail to use the oppo- 
site wrist as a standard of comparison. 

In the interpretation of X-ray plates one should keep in mind 
the more common anomalies as mentioned under the heading of 
"Surgical Anatomy,'' on page 282. The Rontgenographic recog- 
nition of anomalous bones depends on the position and structure 
of the supernumerarj^ ossicle and its presence in the opposite 
carpus. The X-ray plate should show the structure of the bones 
of the carpus as well as their outlines. It should be remembered 
in this connection that the structure of supernumerary bones 
is similar to that of the normal bones of the carpus. This point 
is of importance in distinguishing anomalous bones from fractures. 
The interior of each bone is composed of cancellous tissue while 
the surface is finished off by a thin layer of compact bone. A 
fractured surface will be more or less uneven and the trabeculse 
of the cancellous tissue will open onto the line of fracture. The 
trabeculge of an anomalous bone do not open onto any surface but 
are covered by a thin layer of compact tissue which shows as a 
thin continuous line in the X-ray plate. Anomalous bones are not 
necessarily bilateral, yet if an osseous anomaly of development is 
found in one side of the skeleton an X-ray of the same region on 
the opposite side of the body will almost invariably show a cor- 
responding condition. 

Treatment.- — Reduction of luxations of either the radio-carpal or 
medio-carpal joints is accomplished by traction and counter-trac- 
tion with direct pressure over the prominent displaced carpus. 
It is seldom that difficulty is experienced in correcting the dis- 
placement. There is rarely any tendency to recurrence of 
deformity in uncomplicated cases. Fracture luxation of the wrist 
may tend to recur if the radial fragment is large. Following 
reduction the wrist should be immobilized on a short ventral splint. 
The further conduct of the case will be considered under "After- 
treatment," page 292. Displacement is seldom pronounced in 
fractures of the carpal bones and when reduction is necessarv it 



292 FRACTURES AND DISLOCATIONS 

will usually consist of forcing; prominent fragments back into posi- 
tion. Reduction of luxations of the carpal bones may be readily 
accomplished in some cases by direct pressure, while in other in- 
stances it may be impossible without operative intervention. In 
dorsal luxation of any bone of the carpus the wrist should be 
flexed until the displaced bone is "started" back into the position 
which it previously occupied. When the bone is once "started" 
the hand should be extended until it comes in line with the fore- 
arm, when traction and countertraction are exerted and the carpal 
bone driven home by direct pressure. In the reduction of ventral 
luxations the opposite manipulation is followed. The wrist is 
fully extended, the dislocated bone started back into position, the 
hand then brought to a straight line with the forearm and reduction 
completed. Following any fracture or luxation of the carpus im- 
mobilization is indicated. 

Operative Treatment. — Operation is indicated in compound 
cases and in instances in which reduction cannot be effected by 
manipulation. Closed luxations at the wrist seldom call for op- 
erative measures. Recurrence of deformity in fracture-luxations 
of the radio-carpal joint may require fixation of the radial frag- 
ment. Displaced fragments of carpal bones or a completely lux- 
ated bone may require removal through incision. Old fractures 
or luxations of the carpal bones with restriction of motion due to 
mechanical interference from a luxated bone or displaced frag- 
ment, may require operation with removal of the obstructing bone 
or fragment. 

After-Treatment. — Fixation of the wrist following fractures and 
luxations of the carpus is essential, yet early passive motion is 
equally necessary if the function of the part is to be fully restored. 
It is apparent that non-union of any one of the carpal bones 
would not offer any mechanical obstacle to the full restoration of 
function. Yet, on the other hand, it is a noteworthy fact that 
cases which are allowed free use of the wrist following the acci- 
dent do not show the complete and rapid recovery seen in cases 
treated by proper immobilisation and passive motion. Early unre- 
stricted use of the wrist is followed by a chronic inflammation of 
the synovial surfaces which results in stiffening of the wrist. Pro- 
longed immobilization without passive motion is followed by joint 
adhesions which are equally detrimental to function. The proper 
treatment consists in immobilization of the parts with early passive 



INJURIES TO THE CARPUS 293 

niotiou. Passive motion should be begun as soon as the traumatic 
reaction has subsided and should be repeated at intervals of three 
or four days until the splint is removed. At the end of three 
or four weeks all dressings may be dispensed with and the patient 
instructed to gradually increase the use of the wrist. Massage and 
hot applications are of value in hastening the restoration of func- 
tion. 

Prognosis. — Uncomplicated fractures and luxations of the 
carpus in young or middle aged persons are followed in most in- 
stances by at least a fair restoration of function. In elderly per- 
sons the wrist is likely to remain painful and to show more or less 
restriction of motion in spite of the most painstaking treatment. 
Compound fractures of the carpus, especially crushes, have a much 
more unfavorable prognosis. If infection follows in compound 
cases the chances of a stiff wrist are great, to say nothing of the pos- 
sible loss of function in the fingers due to adhesions between the 
tendons and their sheaths. When function is restricted or pain- 
ful as a result of the displacement of one of the carpal bones, the 
outlook is good, if the condition is corrected by operative meas- 
ures. 



CHAPTER XXI. 

LUXATIONS OF THE CARPO-METACARPAL 
ARTICULATION. 

Surgical Anatomy. — The articulation between the carpus and 
metacarpal bones is heavy and strong, and complete luxations of 
this joint are extremely rare. Promi a surgical standpoint the articu- 
lation may be divided into two parts : first, the articulation between 
the inner four metacarpals and the carpus, and second, the joint 
between the trapezium and first metacarpal. The articulations 
between the inner four metacarpals and the carpus are functionally 
one continuous joint. The synovial cavity extends from the second 
to the fifth joint and is not subdivided by the ligaments. The 
three inner carpal bones articulate with each other above the plane 
of this joint and the metacarpals below^ the joint articulate with 
each other by their lateral surfaces. The inner four metacarpal 
joints are arthrodial in type ; the fifth joint is capable of a wider 
range of motion than the other three. The carpo-metacarpal joint 
of the thumb is one of reciprocal reception (saddle joint) and per- 
mits of motion in all directions except axial rotation. The articu- 
lation between the first metacarpal and the trapezium is sur- 
rounded by a capsule, is separated from the other carpo-metacarpal 
articulations and has its own synovial membrane. All five carpo- 
metacarpal articulations are known to have been luxated, and all 
except that of the little finger have been reported as isolated in- 
juries. Dislocation may occur in one or more of the joints simul- 
taneously, and a number of instances of luxation of all five articu- 
lations have been recorded. Luxation may occur in any direction 
but the most common forms are either forward or backward. The 
lateral support which the inner four metacarpals ofi'er each other 
explains the rarity of lateral luxations. The carpo-metacarpal 
joint of the thumb is the most commonly luxated. Move disloca- 
tions of this joint have been reported than of the other four carpo- 
metacarpal articulations combined. Backward luxations of the 
carpo-metacarpal joint of the thumb are by far the most common. 

294 



LITXATIONS OF CARPO-METACARPAb ARTICULATION 295 

Forward luxations are extremely rare. Luxations of this joint 
are not infrequently complicated by fracture of either the trape- 
zium or base of the first metacarpal or by luxation of the adjoining 
carpo-metacarpal joint of the index finger. Luxation of the carpo- 
metacarpal joint of the index finger is next in order of frequency 
and is more often displaced backward than forward. Luxations 
of the third, fourth and fifth carpo-metacarpal articulations are 
extremely rare. They may be either of the forward or backward 
tj^e. Subluxations, especially of the backward type, are not as 
rare in the four inner metacarpals as in complete luxation. Di- 
vergent luxations have been reported in which some of the meta- 
carpal bases have been displaced backward while others were 
luxated anteriorly. This form of dislocation, however, is extremely 
rare and can hardly be considered as a type. Severe crushing vio- 
lence in this region may produce almost any type of fracture- 
luxation as in the carpus, and because of the superficial position 
of the bones is likely to be compound. 

Symptoms. — In luxations of the carpo-metacarpal joint of the 
thumb there will be loss of function, shortening of the thumb and 
characteristic deformity. In the backward type the base of the 
first metacarpal will be unduly prominent on the dorsal aspect of 
the carpus, just below the end of the radius. In the ventral type 
the trapezium may be palpated and the base of the metacarpal 
forms a hard prominence beneath the thenar eminence. Various 
degrees of angular deformity may be present as well as the over- 
riding displacement. The forward or backward displacement ac- 
companying luxations of any or all of the inner four articulations 
can be appreciated without difficulty if the case is seen early. If 
the injury is not examined before the onset of the traumatic reac- 
tion the swelling may be so pronounced that the nature of the 
deformity is not apparent. The shortening of the fingers, however, 
will be a symptom which will be evident even though the balance 
of the deformity is obscured by swelling. 

Diagnosis. — Luxation of any one of these joints should be recog- 
nized without difficulty if the case is seen early. When four or 
five of the metacarpals are dislocated simultaneously the traumatic 
reaction may be so severe that diagnosis is rendered difficult unless 
the patient is anesthetized or the X-ray resorted to. Fracture of 
either the carpals or metacarpals is not an uncommon complication 
and is recognized by the presence of crepitus. If doubt exists the 



296 FRACTURES AND DISLOCATIONS 

X-ray should be employed. In interpreting X-rays of this region 
the anomalies mentioned under the Surgical Anatomy of "Injuries 
to the Carpus" on page 283, should be kept in mind. 

Treatment. — Reduction is usually accomplished without diffi- 
culty by traction, counter-traction and direct pressure on the dis- 
placed metacarpal base or bases. Luxation of the carpo-metacarpal 
of the thumb is more likely to give trouble in reduction than are 
the corresponding joints of the other fingers. If reduction can- 
not be effected by manipulation open reduction may be necessary. 
A tendency to the recurrence of deformit}^ seldom occurs in any of 
these joints unless fracture complicates the luxation. Following 
reduction the wrist and hand (but not the fingers) should be im- 
mobilized on a short splint. The character of the splint is not 
essential as long as it fits the parts comfortably and effects immo- 
bilization. 

Operative Treatment. — Operation is seldom indicated in the 
reduction of luxations of single joints. In luxations which can- 
not be reduced by manipulation the articulation should be exposed 
by a longitudinal incision and the displacement corrected by direct 
manipulation through the incision. Compound cases should be 
treated as described under "Treatment of Compound Fractures and 
Luxations" on page 789. 

After-Treatment. — The after-care of these cases is practically the 
same as that already given under "Injuries to the Carpus" (page 
292). Early passive motion is most important. 

Prognosis. — The outlook in luxations of the carpo-metacarpal 
articulations is similar to that already given under "Injuries to 
the Carpus." Loss of function in the first carpo-metacarpal articu- 
lation will lead to difficulty in opposing the thumb against the 
fingers, and will constitute a serious handicap in the use of the 
hand. In compound cases the prognosis is much more unfavorable, 
especially in the presence of infection. 



CHAPTER XXII. 

FRACTURES OF THE METACARPALS. 

Surgical Anatomy. — The structure of the metacarpals resembles 
that of other long bones with the exception of the ossification. 
The ossification of the inner four bones is the same. One center 
for the shaft and base, and one for the distal end or head. The 
center for the single epiphysis is first seen about the third year 




Fig. 422. — Fracture of the base of the first metacarpal entering the joint. Bennett's 
fracture. 



and joins the shaft during the twentieth. The metacarpal of the 
thumb has its single epiphysis located at the base. It begins to 
ossify during the third year and joins the shaft in the twentieth. 
Occasionally this bone has an additional epiphysis for the head 

297 



298 



FRACTURES AND DISLOCATIONS 



which is visible at the seventh or eighth year. The first metacarpal 
may thus resemble both phalanx and metacarpal in its process of 
ossification. The positions of the epiphyseal cartilages are of im- 
portance in interpreting Rontgenograms of this region. The shaft 
of a metacarpal is composed of a tube of compact tissue, while the 
extremities are cancellated and enclosed in a thin layer of com- 
pact bone. This change in structure between the shafts and ex- 
tremities accounts for the not uncommon impaction of the shaft into 
the head of the bone following: a blow on the knuckle. Fracture 




Fig. 423. — Gun-shot fracture of the third metacarpal. This plate shows the epiphy- 
sis of the hand at thirteen years of age. Note the single epiphyses of the phalanges 
situated at the proximal ends of the bones. The epiphyses of the metacarpals are 
situated at the distal ends of the bones with the exception of the first metacarpal. 



of the metacarpal shafts usually results from direct violence, while 
fracture of the distal end is almost always caused by indirect 
violence. Fracture of the distal end is almost invariably produced 
in boxing or fighting. A" "punch" is "landed" on some bony 
prominence such as the jaw^ or skull, and the head of the most 
prominent metacarpal is driven upward onto the shaft of the bone 
and also displaced slightly into the palm of the hand. This for- 
ward displacement is due largely to the normal curvature of the 
shaft and to the fact that the palmar aspect of the head is not as 



FRACTURES OF THE METACARPALS 299 

well supported as the dorsal. When the hand is tightly closed in a 
fist the heads of the metacarpals form the prominence of the 
metacarpo-phalangeal knuckles and the impact of violence sustained 
on these knuckles is the most common cause of fracture. Frac- 
ture is not uncommon in any of the metacarpals but is most fre- 
quently seen in the third and fourth. The most usual site of frac- 
ture in the inner four bones is just above the head while the most 
common seat of the break in the metacarpal of the thumb is through 
the base and involving the articular surface. Fracture of the base 
of the first metacarpal is known as Bennett's fracture. The clin- 
ical appearance and X-raj^ findings in this lesion are well shown 
in Figs. 422 to 424. The first metacarpal is isolated and can be 
palpated without difficulty, while the posterior surfaces of the 
inner four bones are subcutaneous and can be palpated from end 
to end unless the hand is markedly swollen, A number of meta- 
carpals may be fractured simultaneously but it is much more 
common to see an isolated fracture of one of them a short distance 
above the head. 




Fig. 42-4. — ^Behhett's fracture in the right hand. Note the abnormal prominence 
at the base of the first metacarpal. Picture taken a few minutes following- the accident. 

Symptoms. — Pain, swelling, tenderness and loss of function are 
constant. The disturbance in function accompanying fracture 
of one or more of the metacarpals usually consists in an inability to 
completely flex the fingers. This is due to pain, swelling and the 
fact that the head of the fractured metacarpal is displaced so that 
there is a mechanical interference with complete flexion of the first 
phalanx. The deformity is usually characteristic (see Figs. 428 
to 433). The head of the injured bone is usually displaced into 
the palm and when the fingers are flexed the corresponding knuckle 
will be found at a lower level than normal. It will often be pos- 



300 



FRACTURES AND DISLOCATIONS 



sible to palpate the head of the bone in the palm of the hand. 
When the fracture is at or near the middle of the shaft the ' ' drop- 
ping" of the kmiekle will be less marked while the backward bow- 
ing of the shaft will be pronounced. Crepitus can, as a rule, be 




Fig. 425. — Bennett's fracture (base of first metacarpal) -with lateral deformity. 
Note the prominence indicated by arrow. Deformity produced by lateral displacement 
of base of metacarpal. 




Fig. 426. — Pressure in the "anatomical snuff box" accentuates the deformity, 




Fij 



-Pressure on the base of the metacarpal effects reduction. 



elicited unless the fracture is near the distal end and impacted. 

Diagnosis. — There should be little difficulty in recognizing frac- 
ture of an}^ of the metacarpals. It is, however, not uncommon to 
see these cases mistaken for and treated as a "sprain." There is 



FRACTURES OF THE METACARPALS 301 

no excuse for this mistake if the parts are carefully examined fol- 
lowing- the injury. The deformity is usually so characteristic and 
pronounced that the diagnosis can be made by inspection alone 
unless the swelling is exceptionally pronounced. Bennett's frac- 
ture is most frequently mistaken for a sprain or subluxation of the 




Fig. 428. — Fracture of the left index metacarpal behind the head of the bone with 
dropping of the knuckle. Note the alignment of the knuckles of both hands and how 
the index knuckle of the patient's left hand is displaced forward toward the palm 
of the hand. Condition about twelve hours old and the result of "punching" someone. 
Motion and crepitus present after the slight impaction is broken up. 




Fig. 429. — Fracture of right index metacarpal of about four years' standing. 
Deformity has been allowed to go uncorrected, knuckle is "dropped" and complete 
flexion of the index finger impossible. Prominence of metacarpal head may be felt in 
the palm. The fifth metacarpal of the same hand was fractured about one month ago 
and the dressings (similar to those shown in Figs. 434, 435, 436 and 437) have just 
been removed. Note how the knuckle of the little finger is up in line with the other 
knuckles. Swelling has not yet entirely subsided and the outline of this knuckle is not 
as sharp as the same knuckle of the opposite hand. 

articulation between the first metacarpal and trapezium. ]\Ianipu- 
lation of the thumb will almost invariably elicit crepitus and dis- 
close the nature of the injury without the aid of the X-ray. 

Treatment. — Reduction of the usual deformity is accomplished 
by traction on the finger corresponding to the injured metacarpal. 
The ligaments connecting the base of the first phalanx with the 



302 FRACTURES AND DISLOCATIONS 

head of the metacarpal are thus employed in pulling the distal 
fragment back into position. During this manipulation the upper 
fragment is to be steadied by the thumb and fingers of the op- 




Fig. 430. — Pronounced "falling" of the index knuckle due to fracture of the second 
metacarpal near its distal end. 




Fig. 432. 



Figs. 431 and 432. — Two views of a recent fracture of the fourth metacarpal near 
its distal end. Note the slight "falling" (ventral displacement) of the fourth knuckle. 
Photographs taken a few minutes following injury, which accounts for the absence of 
swelling. 

posite hand. Seduction is, as a rule, easily accomplished but the 
deformity recurs as soon as the parts are released. The dressings, 
therefore, must be depended upon to retain the fragments in posi- 



FRACTURES OF THE METACARPALS 



303 



tion during the process of repair. It will usually be possible to pre- 
vent overriding' displacement by an engagement of the serrated 
fractured surfaces, but angular deformity can only be avoided by 
proper dressings. The method of fixation which will meet the re- 
quirements in the greatest number of cases is shown in Figs. 434 
to 437. Following reduction a roller bandage is placed in the 
palm, the fingers flexed over it and secured in position by two 
strips of adhesive plaster. A machine rolled bandage such as 
put out by the supply houses should be used to secure the proper 
firmness. A roller four inches wide by ten yards in length is most 




Fig. 433. — Fracture of fourth metacarpal about twenty-five years ago (during 
childhood). Injury to the epiphyseal cartilage with subsequent arrest in growth 
accounts, in part, for the pronounced deformity. 



appropriate. The diameter of this roll, however, is a little too 
great for the average size hand and should be reduced by remov- 
ing the outer layers of the bandage until it is small enough to 
allow the first row of phalanges to be flexed to a right angle with 
the metacarpals as shown in Fig. 434. This position allows the 
head of the broken bone to be ''raised" into line with the other 
knuckles without making upward pressure on the lower fragment. 
After the roller has been placed in position diagonal strips of ad- 
hesive are used as shown in Fig. 436 to raise the injured knuckle. 
The entire hand is then covered with a bandage and carried in a 
sling. 

In some instances the fracture is situated in the shaft and 
oblique enough to prevent a firm engagement of the broken sur- 
faces. Under such circumstances the roller bandage will not cor- 
rect the tendency to overriding deformity and continuous traction 
will be necessary to keep the fragments in proper relation. A nar- 
row splint is properly padded and secured to the palm of the hand 



304 



FRACTURES AND DISLOCATIONS 



by means of strips of adhesive plaster. This splint should extend 
about three inches bej^ond the end of the corresponding finger. 
Extension is then secured by means of light rubber tubing ; one end 
of the tubing is attached to the end of the splint while the other 




Fig. 434. — Roller bandage of appropriate size placed in hand. 




Fig. 43.5. — -Same secured in position by strips of adhesive. 




Fig. 436. — Strips of adhesive used to correct deformity and raise the knuckle of 
the ring finger. 




Fig. 437. — Hand bandaged and dressing complete. 

is attached to the finger by means of strips of adhesive plaster. 

Fractures of any of the four inner metacarpals may be treated 
by means of two splints (dorsal and palmar) properly padded, 
though they are not as reliable and secure as the roller bandage, 



FRACTURES OF THE METACARPALS 305 

unless made of plaster of Paris. If plaster splints are used they 
should be applied with due regard for the nature and tendency of 
the deformity. Eight or ten thicknesses of gauze should be used 
and the material cut so that one splint will cover the dorsal aspect 
of the hand and wrist while the other covers the palm and ventral 
surface of the wrist. These two splints are then soaked in plaster 
cream, wrung out and rapidly secured in position by a roller ban- 
dage. While the plaster is setting the surgeon should grasp the 
hand in such a manner that pressure will be made in the palm 
opposite the displaced head, while counter pressure is exerted 
over the uninjured metacarpals on the dorsum of the hand. This 
raises the injured knuckle and the pressure exerted by the sur- 
geon's fingers is continued by the splints after the plaster has 
set. The splints should be removed as soon as the plaster has 
hardened sufficiently to maintain its proper form, and reapplied 
only after the plaster has thoroughly set and dried out. Placing 
the splints on a radiator or in the sun will hasten the process. 

Fracture of the shaft of the first metacarpal is most satisfactorily 
treated by means of the splint shown in Fig. 440. The curves 
of the thumb and thenar eminence are such that an accurately fit- 
ting splint can be had only bj^ using a material such as plaster 
which can be moulded. Bennett's fracture often requires no splint 
whatever. It is frequently possible to correct the lateral and 
backward displacement of the base of the bone by means of strips 
of adhesive plaster exerting pressure in the direction shown in 
Fig. 427. With the deformity thus corrected the thumb is im- 
mobilized with adhesive strapping similar to that employed in 
the treatment of a sprain. 

Operative Treatment. — Operation is almost never indicated in 
recent fractures of the metacarpals unless the condition is com- 
pound. When the fracture is open it should be treated according 
to the principles laid down under ''The Treatment of Compound 
Fractures and Luxations" on page 789. In old cases with de- 
formity the patient may suffer considerable loss of function with 
persistent pain or tenderness in the palm opposite the displaced 
head. If these symptoms are pronounced and interfere with 
work operation is indicated. The incision is best made on the 
dorsal aspect of the hand and should avoid the extensor tendon 
of the corresponding finger. With the metacarpal exposed the 
bone is divided at the original site of fracture and the knuckle 



306 FRACTURES AND DISLOCATIONS 

raised. The wound is then closed and the condition treated as a 
recent fracture Avith the deformity fully corrected. 

After-Treatment. — The after-care of these cases calls for fre- 
quent inspection of the dressings which are sure to^ become lax or 
slip no matter how well applied. As soon as the dressing becomes 
loose the deformity recurs and thus a deformed hand may follow 
even though the original reduction was perfect. Pressure points 
may show erosion during the after-treatment and call for treat- 
ment. If the roller bandage dressing is used the knuckles under 
the adhesive straps may become irritated and require relief from 
pressure. With the slightest signs of irritation the dressing should 
be reapplied and bits of cotton placed between the adhesive plaster 
and skin. The dorsum of the hand should be carefully watched 
for backward bowing of the shaft of the fractured metacarpal 
which may develop at any time. Direct pressure on the shaft 
may be necessary and is had by means of pads and adhesive 
straps. Backward bowing is not likely to occur if the first 
phalanges are fixed at a right angle with the metacarpals, as 
previously mentioned under "Treatment." Immobilization may 
be discontinued at the end of three weeks but the hand should not 
be subjected to strain for another two weeks as deformity may 
recur. Heavy work should be avoided for two months or more. 

Prognosis. — In an uncomplicated fracture of one of the meta- 
carpals with correction of the deformity there should be complete 
restoration of function. If the deformity is not corrected there 
will be incomplete flexion of the corresponding finger, a weakened 
grip and more or less pain and tenderness in the palm of the 
hand opposite the displaced head. These symptoms will be present 
according to the degree of deformity. 



CHAPTER XXIII. 

FRACTURES OF THE FINGERS. 

Surgical Anatomy. — The phalanges are practically subcutaneous 
throughout and fractures of these bones are, as a rule, detected 
without difficulty. The fleshy pads on the palmar aspect of the 
fingers are comparatively thick, and palpation on this side of the 
digit is less satisfactory than elsewhere. The quadrilateral ex- 
panded bases may be palpated without difficulty. The internal 
structure of the phalanges is similar to that found in other long 
bones. The extremities are composed of cancellous tissue covered 
by a thin layer of compact bone, while the shafts consist of tubes 
of heavy compact tissue. Accordingly fractures occurring in the 
extremities are more prone to show comminution and crushing of 
cancellous tissues, while breaks through the shafts are usually 
clean cut and never impacted. 

The dorsal aspect of each finger, from the head of the meta- 
carpal to the base of the terminal phalanx, is in contact with the 
extensor tendon. The anterior aspect of each digit is in relation 
with the flexor tendons. The tendons of the flexor sublimis dig- 
itorum are inserted into the sides of each middle phalanx, while the 
tendons of the flexor profundus digitorum are inserted into the 
bases of the terminal phalanges. These tendons and the synovial 
sheaths enclosing them are of considerable importance in the 
treatment of fractures of the fingers. Prolonged immobilization, 
following the traumatic inflammation which accompanies fractures, 
is likely to give rise to adhesions between these tendons and their 
sheaths; such adhesions limit motion after recovery takes place. 

Epiphyseal separations are rare in the fingers though they are 
occasionally seen. Each phalanx is ossified by two centers, one 
for the base and one for the head and shaft. The bases of the 
proximal row of phalanges begin to ossify during the third or 
fourth year and join the shafts at about the eighteenth year. 
The shafts of all the phalanges show signs of ossification soon after 
birth. 

307 



308 



FRACTURES AND DISLOCATIONS 



The prominences of the knuckles do not correspond to the planes 
of the joint but are formed by the heads of the bones above the 
articulation. The digital vessels and nerves run on either side of, 
and a little ventral to, the lateral borders of the phalanges. 

The use to which the hands are put in the different trades and 
in various types of labor exposes the fingers to all kinds of direct 
violence. This is particularly true of those working about ma- 
chinery. The fact that the phalanges are subcutaneous results in 
a high proportion of compound fr'actures and luxations, even 




Fig. 438. — Gompound fracture of the base of the terminal phalanx of the middle 
finger with backward displacement and tearing of nail from its bed. 




Fig. 439. — Severe compound fractures of the proximal phalanges of the fourth and 
fifth fingers. Wounds on ventral aspect of fingers. Injury sustained in machine ac- 
cident. 



though the skin covering these parts is heavy and strong. Frac- 
tures of the fingers, especially those produced by machinery, are 
often accompanied by severe and extensive laceration and bruis- 
ing of the overlying soft tissues. 

Symptoms. — Local pain, loss of function and swelling of the 
injured finger are almost invariably present. Crepitus and ab- 
normal mobility can usually be elicited without difficulty. When 
the fracture is near the end of the phalanx the point of preter- 
natural mobility may be difficult to recognize because of the prox- 



FRACTURES OF THE FINGERS 309 

imity of the joint. Crepitus is not as easily elicited when the 
break is near the end of the bone. Deformity varies considerably ; 
it may be pronounced enough to establish the nature of the injury 
by inspection alone, or it may be absent. A type of injury known 
as ''base-ball finger" consists of fracture of the terminal phalanx 
with impaction, as shown by the X-ray, but the symptoms do not 
conform to the symptoms accompanying the usual fracture. The 




Fig. 440. 



Fig. 440. — Plaster splint applied to thumb. The curves of the thumb from v/rist to 
thumb-tip are such that it is diflicult to obtain a good fit with any other form of splint. 

Fig. 441. — Plaster splint applied to dorsal surface of middle finger and back of 
hand. Secured in place by means of strips of adhesive. 

injury is produced by being struck on the end of the finger by a 
base-ball. Following the trauma the finger is painful and tender 
and somewhat swollen, but mobility and crepitus are usually ab- 
sent. There is a slight deformity which can not be recognized 
until the swelling subsides. These fractures are often overlooked 
if the case is not examined with the Rontgen ray. Recovery is 
usually slow, the finger remaining tender and painful for weeks 
and even months. 



310 FRACTURES AND DISLOCATIONS 

Diagnosis. — Fractures of the fingers can be recognized without 
difficulty if the parts are carefully examined following the injur}^ 
When deformity is present there may be a tendency to recurrence 
of displacement following reduction but this is seldom the case in 
dislocations. The finger nail renders the terminal phalanx difficult 
to palpate, and the typical base-ball fracture cannot ordinarily 
be recognized in this way. The X-ray should be used when there 
is doubt. 

Treatment. — The proper treatment of fractures of the fingers is 




Fig. 442. — Splint of cigar-box wood padded, bandaged and placed in position to im- 
mobilize middle finger. Note the cotton in palm of hand. 

of greater importance than would at first appear since there is 
only a small proportion of men who do not depend, at least 
partially, on their hands for a livelihood. A crippled hand often 
means impaired earning capacity. 

When there is deformity it should be corrected at the earliest 
possible moment and the finger immobilized. In fractures of the 
phalanges it has been customary to immobilize the injured finger 
in a position of complete extension. A position of slight flexion, 
however, will be found much more comfortable since the flexor 



FRACTURES OF THE FINGERS 



311 



and extensor tendons more nearly balance each other in this at- 
titude. A straight palmar splint may be used as shown in Fig. 
442, but the padding should be so arranged that the surface coming 
in contact with the finger will present a slight curve. The splint 
is secured in position with strips of adhesive plaster. If the digit 
is immobilized soon after the accident the dressings should not 
be too tightly placed, as otherwise strangulation may take place 
when the finger swells. Copper wire may be used as a splint, but 
when this is done padding should first be placed about the finger. 
The most perfect splint is made with plaster of Paris and gauze or 
crinoline. (See Figs. 4-40 and 441.) This form of splint fits the 




-^^a 



FU. 443. 




444. 



Fig. 445. 



Fij. 443. — The Goldthwaite tin, thumb splint in position. A layer of cotton should 
be used to keep the metal from coming in contact with the skin. 

Fig. 444. — Pattern from which the Goldthwaite splint is made. 

Fig. 445. — The finger splint padded and held in position by strips of adhesive. 

parts perfectly because it is moulded to them and the finger may 
be placed in any degree of flexion according to the needs of the 
case. When the fracture is compound anteriorly the splint may be 
placed on the dorsal aspect of the hand and will hold the parts 
securely. 

Compound fractures should be treated according to the prin- 
ciples laid down under the heading of ''Treatment of Compound 
Fractures and Luxations" on page 789. Ethereal antiseptic soap 
will be found of considerable advantage in the removal of dirt and 
grease from the hands of mechanics and machinists preparatory to 
washing the wound with salt solution. 

Operative Treatment. — Operation is rarely indicated in frac- 
tures of the fingers except in compound cases. The wound should 



312 FRACTURES AND DISLOCATIONS 

be treated according to the principles set forth on page 789. 
Lacerated tissues should be trimmed away and the wound thor- 
oughly irrigated before the edges are approximated. If the frac- 
ture is produced by some cutting instrument and the tendons 
divided they should be repaired before the wound is closed. In 
severe crushes of the fingers amputation may be necessar\\ 

After-Treatment. — During the after-treatment the finger should 
be carefully watched to keep the dressings properly adjusted and 
to prevent recurrence of deformity. If the trauma accompanying 
the fracture has been great it may be best to postpone the applica- 




Fig. 446. — The result of saving too much of the finger in crushes of the terminal 
phalanx. The base of the nail hed has been left which produces the heavy claw-nail 
which is a continual source of annoj-ance. 

tion of splints until the swelling has subsided. During this time 
the finger is immobilized by surrounding the digit with cotton and 
bandaging the adjoining fingers to it. The ice cap will tend to 
control the traumatic reaction. Fixation should be maintained 
for a period of three weeks in uncomplicated cases, but guarded 
passive motion begun at the end of ten days will be of the greatest 
advantage in preventing adhesions within the joints and between 
the tendons and their sheaths. In compound cases the greatest 
care should be exercised to prevent infection and suppuration of 
the wound following the initial treatment. If infection becomes 
established necrosis of bone and non-union are likely to follow. 
If necrotic bone is present it should be removed as soon as possible 



FRACTURES OF THE FINGERS 313 

aud an attempt made to convert the suppurating sinus into a 
health}^ wound. If union is not present at the end of four or five 
weeks it is probable that it will never occur especially without 
surgical intervention. Under these circumstances it may be best 
to amputate. In crushes of the terminal phalanx the inad vis- 
ability of attempting to save the base of the nail bed is shown in 
Fig. 446. As shown in this case the nail forms a heavy, de- 
formed annoying protuberance. 

Prognosis. — The outlook in fractures of the fingers depends 
entirely on the severity of the injury. In simple cases recovery 
should be complete while in severe crushes it may be impossible 
to avoid amputation, to say nothing of obtaining union in the 
fractured phalanx. The accompanying injury sustained by the 
soft tissues is a most important element. 



CHAPTER XXIV. 

DISLOCATIONS OF THE FINGERS. 

Surg-ical Anatomy. — The articulations between the metacarpal 
bones and the proximal row of phalanges are condyloid in type 
and permit of flexion, extension, adduction, abduction and cir- 
cumduction. A variable amount of hyperextension is normal in 
these joints and varies in different individuals. These joints are 
held together by two lateral and one ventral ligament. The place 
of the posterior ligament is taken by the extensor tendon which 
crosses the articulation. The interphalangeal articulations are 
typical hinge joints and permit only of flexion and extension. A 
greater degree of flexion is possible in the proximal interphalangeal 
joint than in the distal articulation, though in the latter a greater 
degree of hyperextension is usually possible. The ligaments re- 
semble those of the metacarpo-phalangeal joints; there are two 
lateral and one ventral ligament, the function of the posterior 
ligament being performed by the extensor tendon. The metacarpo- 
phalangeal articulations of the thumb and forefinger are more 
often dislocated than the three corresponding joints of the mid- 
dle, ring and little fingers taken together. The displacement may 
be backward, forward, or lateral, and there may be overriding as 
well as angular deformity, and not infrequently the condition is 
compound. The anterior ligament is heavy and rigid and in back- 
ward luxations it is usually torn away from the metacarpal bone 
and may become interposed between the bones and offer obstruc- 
tion to reduction. Backward luxation of the metacarpo-phalangeal 
articulation of the thumb is not an uncommon injury, and occa- 
sionally offers considerable resistance to reduction. This is due 
to the interposition of the' anterior ligament and is probably not 
the result of the metacarpal head becoming caught between the 
tendons of the flexors of the thumb, as is commonly thought. 
Any of these luxations may be complete or incomplete according 
to the extent to which the phalanx has been displaced. Luxations 
of the interphalangeal joints are similar to those occurring between 

314 



DISLOCATIONS OF THE FINGERS 



315 



the metacarpals and proximal row of phalanges. The types of 
displacements are the same and the mechanism which obtains is 
similar. 




Fis. 447. — Dislocation of the thumb. Common form. 





Fiii-. 448. 



Fig. 44 9. 



Figs. 448 and 449. — Ventral and dorsal views of a compound dislocation of the 
terminal phalanx of the thumb. When an articular surface is exposed as this one is 
it should be thoroughly cleansed before reduction. (See "Operative Treatment of Com- 
pound Fractures and Luxations," Chapter LXI.) / 




Fig. 450. — Old outward dislocation of thumb which was never reduced. Picture 
taken years following injury. 

Diagnosis. — The recognition of these luxations is too easy to 
require description. The patient will almost invariably diagnose 



316 



FRACTURES AND DISLOCATIONS 






Fig, 451. 




Fig. 452. 

Figs. 451 and 452. — Recent backward dislocation of the second phalanx of the 
middle finger the result of a twisting strain. Base of the second phalanx lies behind 
the head of the first phalanx. Reduction easily accomplished by traction and counter- 
traction followed by flexion. 




Fig. 453. — Yentral dislocation of second knuckle. Easily reduced. 




Fig. 454. — Backward dislocation of left index finger. The head of the first 
phalanx projects through the skin. This type of dislocation almost invariably becomes 
compound by tearing of the skin on the- ventral aspect of the finger opposite the joint. 



DISLOCATIONS OF THE FINGERS 317 

the nature of the injury before the surgeon sees him. Compli- 
cating fracture of the base of the distal phalanx is, however, occa- 
sionally overlooked. 

Symptoms. — The injured finger is immediately thrown out of 
function and the accompanying pain is usually severe. The de- 
formity is apparent and characteristic and varies according to the 
nature and direction of the luxation. The accompanying illustra- 
tions will serve to convey an idea of the appearance of these joints 
immediately following the different forms of dislocation. (See 
Figs. 417 to 455.) 




Fig. 455. — Backward luxation of tlie seroiid .ioint of the middle finger. Dislocation 
rendered compound by wound on ventral surface of finger opposite the joint. Wound 
similar to that seen in Fig. 454. 

Treatment. — In simple cases reduction should be effected as soon 
as the case is seen. In compound luxations the displacement 
should not be corrected until the wound and exposed articular or 
synovial surfaces have been thoroughly cleaned and irrigated 
with salt solution, as will be described under the heading of 
''Treatment of Compound Fractures and Luxations" on page 789. 
The manipulations employed in reduction vary with the type of 
displacement and consist of sliding the base of the displaced 
phalanx back onto the head of the proximal bone. In a complete 
luxation with overriding deformity traction and counter-traction 
may prove inefficient and when such is the case the angular de- 
formity should be increased until the edge of the base of the distal 
bone is started onto the head of the proximal bone, whether it 



318 FRACTURES AXD DISLOCATIONS 

be metacarpal or phalanx. The principles involved are similar to 
those employed in reducing fractures of the bones of the forearm 
where the fractured surfaces are engaged before the angular de- 
formity is corrected. If the surgeon appreciates the conformation 
of the articular surfaces entering into the joint and the nature 
of the displacement there should be little difficulty in accomplish- 
ing reduction in uncomplicated cases. 

Operative Treatment. — Operative treatment is indicated in com- 
pound cases and in instances in which some tissue., such as the 
anterior ligament, prevents reduction by manipulation. In com- 
pound cases the wound usually consists of a transverse tear on the 
ventral aspect of the joint and it is of the greatest importance that 
this Avouud be thoroughly cleansed and irrigated before the luxation 
is reduced. If infection follows a compound luxation it is probable 
that motion will be lost in the finger as a result of adhesions within 
the joints and between the tendons and their synovial sheaths. 
(See "Treatment of Compound Fractures and Luxations," page 
789.) 

After-Treatment. — Following reduction the injured articulation 
should be put at rest to allow healing of the torn ligaments. 
Early passive motion, however, is essential to the subsequent 
restoration of function. A satisfactory plan is to treat the in- 
jured member in a position of extension for the first three or four 
days and then to remove the dressing, flex the finger to break up 
forming adhesions, and immobilize it in this position for a similar 
period. These periods of flexion and extension are repeated until 
the after-treatment is complete. Thus, when adhesions are broken 
up within the joint or in the tendon sheaths and the position of 
the finger changed, the denuded synovial surfaces no longer remain 
opposed and the chances of the adhesions reforming are reduced. 
A straight splint may be used for the extended position and a 
roller bandage, such as is used in the treatment of fractures of 
the metacarpals (see page 304), may be used to immobilize the 
finger in flexion. Healing, of the torn ligaments should be suffi- 
ciently far advanced at the end of two weeks to allow guarded use 
of the injured flnger. In infected cases it may be Cjuite difficult 
or even impossible to reestablish motion after the wound has 
healed, and if the infection is severe it may necessitate multiple 
incisions for the evacuation of pus along the course of the synovial 
sheaths and in the tissues surrounding them. 



DISLOCATIONS OF THE FINGERS 319 

Prognosis. — In simple cases restoration of function should be 
complete with proper treatment although a small degree of flexion 
may be permanently lost. In compound cases followed by infec- 
tion, the prognosis will depend entirely on the virulence of the 
invading organism, the resistance of the patient and the treatment 
he receives. A serviceable joint may follow in a compound in- 
fected case, but the chances of a stiff finger are great and the 
patient should be made to appreciate this fact early in the after- 
treatment. If the infection is severe amputation may be neces- 
sarv. 



PART II. 
HEAD AND TRUNK 



CHAPTER XXV. 

FRACTURES OF THE NOSE. 

Surgical Anatomy. — The bony framework of the nose comprises 
not only the two nasal bones, but also the nasal processes of the 
superior maxilla, the bony septum and the nasal spine of the 
frontal. The nasal bones consist of two small, oblong, quadri- 
lateral bones situated at the bridge of the nose. These bones 
articulate laterally with the processes of the superior maxillge, 




Fig. 456. 



Figs. 456 and 457. — Sagittal section through the nasal cavity. F. R., Vertical 
plate of frontal; N., Nasal bone: N. S., Nasal spine; N. P., nasal process of superior 
maxilla; G. G., Crista Galli; S.T., Superior turbinate; M. T., Middle turbinate; I. T., 
Inferior turbinate; S., Body of sphenoid; Pal., Palate bone; P.P., Palatal process of 
superior maxilla. 

above with the frontal (at the nasion) and in the median plane 
with each other. The two nasal bones meet in the median line 
and rest upon the spine of the frontal in much the same manner 
as the rafters of a roof rest upon the king-beam. This nasal spine 
is, in turn, backed up by the vertical plate of the ethmoid. This 
continuity of bony tissue, from the nasal bone to the christa galli, 
explains the possibility of a blow on the nose displacing the ver- 

323 



324 FRACTURES AND DISLOCATIONS 

tical plate of the ethmoid upward into the anterior fossa of the 
skull. In 3^oung subjects the articulations in the bony framework 
of the nose are distinct and contain more or less intersutural tis- 
sue, but in old age the sutures are ossified and the different bones 
become continuous. It is therefore evident that in the aged a 
greater amount of the trauma of the nose injuries is transmitted 
to the vertical plate of the ethmoid and septal complications are 
more common. 

The lower half of the nasal bone is thinner and more friable 
than the upper half ; the inferior border is sharp and has attached 
to it the upper lateral cartilages of the nose. In the less severe 
cases fracture is limited to the lower portion of the nasal bones 
because of the more exposed position and weaker construction. 

The deep surface of the nasal bones is covered by mucous mem- 
brane which is commonly lacerated in fracture with displacement, 
and hence fractures of the nasal bones, which are usually considered 
simple (and are simple as far as the skin is concerned) .are in 
reality rendered compound by laceration of the mucous lining on 
the deep surface. 

The bony septum is composed of the vertical plate of the eth- 
moid above and the vomer below (see Fig. 457). 

The angular interval between the ethmoid and the vomer is 
filled in by the cartilaginous septum. This cartilaginous septum ar- 
ticulates with the antero-inferior border of the vertical plate of 
the ethmoid and is continued into the vomer below. The junction 
of the cartilaginous septum with the anterior border of the vomer 
is peculiar because of the unusual manner in which the vomer is 
ossified. The ossification of the vomer begins in a single center 
and spreads in such a manner that two lateral plates of bone result, 
with a median layer of cartilage between them, which is continuous 
anteriorly with the quadrangular septal cartilage of the nose. 
Union between the two lateral plates of bone does not take place 
until after puberty. This peculiar arrangement results in the 
articulation between the vomer and the cartilage being stronger 
than the upper articulation between the ethmoid and the same 
cartilage. These anatomical points, together with the fact that the 
trauma is more directly transmitted to the upper part of the sep- 
tum, account for the more frequent displacement taking place 
between the ethmoid and the quadrangular cartilage in youth. 
Unless the interior of the nose is carefully inspected early in the 



FRACTURES OF THE NOSE 325 

treatment, septal displacements may go unrecognized during the 
time that treatment would be most efficient. 

The angular artery and vein (continuations of the facial vessels) 
axe found running in a nearly vertical direction behind and 
lateral to the nasal bones, in which position they may give rise to 
troublesome hemorrhage when injured in severe compound frac- 
ture of the nose. 

The nasal nerve, a branch of the ophthalmic division of the 
trifacial, runs longitudinally on the internal surface of the nasal 
bone after having passed from the orbit to the nasal cavity by 
way of the anterior ethmoidal foramen and nasal slit. 

The upper portion of the vertical plate of the ethmoid is grooved 
for the passage of the ethmoidal nerves from the Schneiderian 
membrane to the olfactory bulb. The nasal nerve is, strictly 
speaking, a nerve of sensation, while the olfactory nerves have to 
do with the sense of smell ; the juxtaposition of these nerves with 
the bones involved accounts for the frequent disturbances of smell 
and sensation following fractures in this region. 

The mucous membrane of the nose is highly vascular, and in 
cases where a large vessel is lacerated we may experience consider- 
able difficulty in controlling hemorrhage. 

Etiology. — Fractures of the nasal bones and adjoining bony 
structures are the result of direct violence, such as blows on the 
face, falls and trauma sustained by various means. Fractures of 
the nasal bones constitute between four and five percent of all 
fractures. The injury is most commonly seen as the result of 
brawls. 

Symptoms. — The prominent symptoms of fracture of the nose 
are deformity, mobility and crepitus. Swelling of the soft parts 
rapidly follows the trauma and epistaxis is practically constant 
and appears immediately following the injury. There is more or 
less obstruction to nasal respiration, depending upon the inward 
displacement of the fragments, the swelling of the mucous mem- 
brane and the accumulation of clotted blood within the nasal 
cavities. The more extensive the region involved by fracture and 
the more pronounced the trauma, the greater the frequency of 
pronounced nasal obstruction. In severe cases where the fracture 
extends well backward involving the nasal canal, in the nasal 
process of the superior maxilla, we may have obstruction of the 
nasal duct with consequent lachrj^mation of the affected side. Oc- 



326 



FRACTURES AND DISLOCATIONS 



casionally we have emphysema of the ej^elids and face as a result 
of air having been forced from the nasal passages into the sub- 




Fig. 459. 



Fig. 458. — Old fracture of nasal bones ^vith lateral displacement. 
Fig. 459. — Old fracture of nasal bones with lateral displacement. 




Fig. 460. 



Fig. 461. 



Fig. 460. — Separation and angular disylacemeiit of lateral and septal cartilages to 
patient's right. 

Fig. 461. — Fracture of nasal bones with displacement to right. Partial separation 
of lateral and septal cartilages with displacement to left. 



cutaneous cellular tissue. The nature of the late symptoms will 
vary according to the presence or absence of infection. The cir- 



FRACTURES OF THE NOSE 



327 



eulation is extremely free iu this region, the vitality and resistance 
of the tissues great, and accordingly we find recovery more prompt 
and complete than might otherwise be expected. Necrotic bone is 
seldom seen, and infections, except when virulent, are short-lived. 
Suppuration, however, when once established, may persist for 
weeks if there are particles of necrotic bone present. The dis- 
charge will keep up until these pieces have been removed or 
thrown off. 

Diagnosis. — Diagnosis of fracture of the nose is based upon the 
symptoms already enumerated ; deformity, mobility and crepitus. 




Figs. 462 and 463. — Two views of a case of destruction of the nasal bridge due to 
syphilis. Deformity resembles deformity following severe fracture. 



Deformity, as observed in these cases, is not as reliable from a 
diagnostic standpoint as it is in fractures of other regions. This 
fact is due to the variability of the normal nasal outline together 
with the frequent presence of old unreduced deformities following 
previous fractures. 

If the bridge of the nose is gripped between the thumb and the 
index finger the stability of the bones may be ascertained and 
crepitus elicited. The question of mobility is rather variable. 
During examination it is not infrequently possible to displace the 
fragments from side to side with but slight effort; but on the 
other hand, we often see cases in which the bones have been for- 



328 



FRACTURES AND DISLOCATIONS 



cibly displaced to one side and have apparently become wedged, 
requiring considerable force to return them to their normal rela- 
tions. A long slender instrument similar to the divider, when 
properly passed upward behind the seat of fracture, will enable 




Fig. 464. — Falling in of cartilages in old case of syphilis. 




Fig. 46.5. — Case of saddle nose due to hereditary syphilis. 



the surgeon to determine the internal contour of the nasal frag- 
ments. The diagnosis of fracture of the nose cannot be considered 
complete without ascertaining the condition of the osseous and 
cartilaginous nasal septum. This may be accomplished by direct 
inspection or by palpation with a probe. 



FRACTURES OF THE NOSE 



329 



Treatment. — In dealing with fractures in this region the treat- 
ment must var}- according to the severity of the injury. Severe 
compound comminuted fractures may, at times, become extremely 
difficult to manage. The indications must be considered in each 
and every individual case. Displacement, when present, must be 
corrected, and the fragments maintained in proper apposition. Ke- 




Fig. 466. 



Fig. 467. 



Fig. 466. — Raising the nasal bones by means of "divider" within the nasal cavity 
and moulding them into position vs^ith the thumb aiad index linger. 

Fig. 467. — Packing nasal cavities with strips of gauze soaked in adrenalin to control 
hemorrhage and support bridge of nose. 

duction is usually best accomplished by combined external and 
internal manipulation. A small slender instrument which will 
approximately fit the posterior surface of the nasal bone is passed 
upward into the nose, the fragment raised and pushed back into 
position, with the assistance, externally, of the thumb and index 
of the opposite hand. 




Fig. 468. — Asche nasal splints. (Different sizes.) 

Both sides should be adjusted in this manner, and the contour 
of the nose carefully inspected and palpated to produce as sym- 
metric a result as possible. At the same time we must be pre- 
pared to readjust the septum when it shows lateral displacement. 
The injuries seen in the septum are numerous, involving for the 
most part the quadrangular cartilage and the vertical plate of 



330 



FRACTURES AND DISLOCATIONS 



the ethmoid; the important point as far as treatment is concerned 
is the tendency toward displacement after the nasal bones have 
been replaced. Lateral bowing of the septum or overriding of 
the fragments should be reduced, and if there is tendency to re- 
currence of deformity some means of maintaining reduction must 
be employed. The tubular nasal splint will often accomplish all 
that is required but if some more secure method is needed pins 
may be introduced to hold the septum, as suggested by Roberts.^ 

Hemorrhage from the torn mucous membrane may be severe, but 
even when moderate at the time of examination there is no assur- 
ance that it will not be profuse a few hours later; it is therefore 





Fig. 469. Fig. 470. 

Fig. 469. — Author's moulded, dental composition, nasal splint. 
Fig. 470. — The Cobb nasal splint. 

wise to pack the upper anterior portion of the nasal cavity at the 
first treatment. This will maintain the fragments in proper posi- 
tion and also serve as a pack to control hemorrhage from the 
lacerated portion of the mucous membrane. It is usually not 
necessary to pack the parts tightly enough to bulge the bridge of 
the nose ; the strip of gauze however should be carried well up 
under the nasal bones before the packing is begun. ,If these 
strips of gauze are previously saturated with a 1 to 1,000 adrenalin 
chlorid solution we have an additional preventive against hem- 
orrhage. When the case is first seen hemorrhage is, as a rule, 
the most important element to be dealt with, and for this reason 
it is best to employ the pack rather than the nasal splint, which 



1 "Surgery of Fractures and Dislocations of the Nose," in Stirg., Gynec. and Obstet. 
June, 1911. John B. Roberts, M.D, 



FRACTURES OF THE NOSE 331 

finds a more appropriate place iu the after-treatment of the case. 
AVe should attempt to reduce deformity immediately following 
injury, yet, if the hemorrhage is pronounced, it should be con- 
trolled even at the expense of perfect reduction. Later on when 
the danger of hemorrhage has passed, more accurate adjustment 
of the fragments may be made, and one of the various forms of 
nasal splint, commonly in use, emploj^ed. The same trauma which 
produces the fracture not infrequently lacerates the skin over the 
nose. "When this is the case, we have the wound to treat as 
well as the fracture. Wounds when present should be thoroughly 
cleansed and the edges approximated. If the margins of the 
wound show much laceration the ragged edges should be trimmed 
away with a sharp scalpel before the sutures are placed. Either 
local or general anesthesia is advisable except in the most mild 
type of case. If the nose is gently packed for a few minutes 
with strips of gauze saturated in a four percent solution of co- 
caine, subsequent manipulations will be rendered almost free from 
pain and the surgeon's work is made much easier. 

Operative Treatment. — There is little in the way of operative 
treatment in these cases aside from that already described. There 
are exceptional cases, however, in which it may be necessary to 
reconstruct the bridge of the nose or to correct old deflections of 
the septum or nasal bones which have resulted from old unre- 
duced fractures. Pronounced depression may result either from 
the original trauma or from subsequent infection and sloughing. 
Syphilis is still another cause of falling of the bridge or cartilages 
and the resultant deformity should not be confused with the trau- 
matic condition. Syphilitics often misrepresent their case and 
unless the surgeon recognizes the luetic nature of the condition, 
he may perform a plastic operation on the nose of an active 
syphilitic, while the specific processes are still destructive. 

In correcting deflections and depressions of the bridge an at- 
tempt is made to bring the displaced portions of bone back into 
position after having refractured them as near as possible to the 
original seat of fracture. Much can be accomplished in the lower 
portion of the bone by incisions through the mucous membrane on 
the deep surface of the bones. When the deflection begins high 
up near the frontal refracture may be accomplished by a small 
subcutaneous incision and narrow chisel. After the displaced 
fragments have been refractured they are brought back into posi- 



332 FRACTURES AND DISLOCATIONS 

tioii and treated the same as a recent fracture. The septum re- 
quires attention and when deflected it may become necessary to 
do a submucous resection, as is done for deflections resulting from 
causes other than fracture. In some cases of saddle nose there is 
not sufficient bony tissue from which to reconstruct the bridge and 
the problem then becomes one not only of plastic surgery but also 
of bone transplantation. A bone transplant ol appropriate size 
and shape is taken from the crest of the tibia, introduced within 
the tissues of the nose and the soft parts closed over it according 
to the plastic method best suited to the case in hand. When the 
bone transplant is used it should be shaped and placed to flt the 
needs of the particular case, and the denuded osseous material of 
the transplant should be brought firmly in contact with the de- 
nuded surface of the living bone, so that the reformative osteo- 
genetic elements may find their way from the living bone into the 
transplant during the process of repair. The injection of paraffin 
to correct nasal depression has often been followed by satisfactory 
results, but on the whole cannot be recommended except in rare 
cases. 

The most satisfactory suture, except where there is considerable 
tension of the parts, is horse-hair. 

After-Treatment. — The gauze packs should not be allowed to 
remain in place more than forty-eight hours at the most and we 
should exercise the greatest gentleness in their removal in order 
that we may avoid the recurrence of hemorrhage. If the packs 
are allowed to remain longer they become foul, thus favoring in- 
fection and suppuration. We occasionally meet with cases in 
which both primary and secondary hemorrhage are difficult to 
control. If hemorrhage follows the removal of the packs, the 
inside of the nose is to be inspected to determine whether we have 
a general oozing or a hemorrhage from a single vessel. In cases 
where loss of blood from a single vessel is persistent it may become 
advisable to touch the bleeding end with a small electro-cautery. 
When the dangers of hemorrhage and infection are past the re- 
maining desideratum consists in maintaining the fragments in 
position until union has taken place. In most cases the simple 
nasal splint (Asche splint) fitted into the upper nares will suffice. 
A slight degree of pressure may be maintained from the outside 
by strips of adhesive plaster applied across the bridge of the 
nose. Various types of complicated external nasal splints (such 



FRACTURES OF THE NOSE 333 

as the Cobb, Eisendratli, Neres, etc.) have been devised and nsed 
with success, but it is only in rare instances that they are of real 
service. 

"When external pressure is necessary to maintain the fragments 
in proper position we may employ the following method which 
is quite efficient and simple. A piece of dental composition, hav- 
ing been rendered pliable by immersing it in hot water, is applied 
to the nose and a mould of the parts taken Avith such pressure as 
may be necessar}^ to maintain proper reduction. Cold water is 
then poured over the composition to harden it before removing 
it from the nose. The newly formed splint is then removed and 
trimmed as desired, after which it is replaced and secured by means 
of strips of adhesive plaster (see Fig. 469). If thought desirable, 
additional leverage may be obtained by extending the splint up- 
ward onto the forehead where it is again secured by transverse 
strips of adhesive. It is better not to employ any form of moulded 
splint until after the acute swelling has subsided, which will take 
from three to four days ; — on the other hand, delay beyond the 
fifth or sixth day is not advisable since union in this region is 
often rapid. External pressure, however, is rarely needed if the 
essentials previously mentioned are properly followed out. Union 
should take place in the average adult in from ten days to two and 
a half weeks but it will be over a month and a half to two 
months before the parts should be subjected to any considerable 
pressure, and the patient should be cautioned in this regard. 
During the course of after-treatment the internal nasal splints 
should be removed at intervals of three to four days, and nasal 
douches employed daily to prevent the parts from becoming foul. 
Normal salt solution or one of the mild alkaline antiseptic washes 
will be found satisfactory as a douche. Subcutaneous emphysema, 
ecchymosis and swelling will, as a rule, subside during the first 
few days without the use of any special method for their relief. 

Prognosis. — The prognosis is almost invariably good, yet we 
cannot guard too carefully against infection in this region. The 
deformity is almost always a matter subject to correction and aside 
from exceptional cases the ultimate cosmetic results should be 
good. 



CHAPTER XXVI. 

FRACTURES OF THE MALAR BONE AND 
ZYGOMATIC ARCH. 

Surgical Anatomy. — Anatomically speaking; the malar is a 
distinct bone, but from a surgical standpoint it becomes neces- 
sary to consider the various processes with which it articulates as 
a part of that bone, since fractures are rarely limited to the 
malar alone. The bone is roughly quadrilateral in shape, articu- 
lates with the frontal, great wing of the sphenoid, zygomatic 
process of the temporal and the malar process of the superior 
maxilla. It also forms part of the wall of the temporal and 
zygomatic fossae and enters into the formation of the orbit. The 
bone is composed of heavy compact tissue, its strength being such 
that blows on the face usually result in impaction of its supports 
rather than fracture of the bone itself. The fact that the malar 
enters into the formation of the wall of the orbit and the zygo- 
matic fossa, Avill lead to symptoms peculiar to these cavities when 
the bone is displaced. From a surgical standpoint the zygomatic 
arch is to be considered as a whole, and since the zygomatic process 
of the temporal and the malar both enter into its formation, these 
two structures are spoken of as one. The space beneath this arch 
is normally filled by the coronoid process of the inferior maxilla 
and the temporal muscle, and any inward displacement of the 
arch must encroach upon these structures and interfere with their 
function. Interference with the action of the lower jaw may some- 
times result from the extravasation of blood or from swelling of 
the tissues beneath the arch, and we thus have a symptomatic 
simulation of bony depression. So-called fracture of the malar 
consists chiefly in impaction of the bone into the processes sup- 
porting it, especially that of the superior maxilla. The largest 
process supporting the bone is the malar process of the superior 
maxilla, and since the antrum of Highmore projects well up into 
this process (sometimes even penetrating into the malar) the frac- 
ture may open into the cavity of the antrum; when such is the 

334 



FRACTURES OF MALAR BONE AND ZYGOMATIC ARCH 335 

case the manner in which air may be forced from the nasal cavity, 
through the antrum, into the conjunctiva, is evident. Thus the 
resulting subconjunctival emphysema, when present, indicates the 
condition of the underlyino- bone. 




Fig. 471. — Relations of the nasal, lachrymal, superior maxilla and malar bones. 




Fig. 472. — Zygomatic arch seen from below. Note the relations of the arch and the 
inferior maxilla. 

In fracture of the malar the usual deformity consists in depres- 
sion of the bone into the superior maxilla with a slight rotary dis- 
placement, so that the orbital border may be felt projecting into 
the orbit while the zygomatic process is displaced inward and 
downward (see Fig. 471). The malar is sometimes displaced 



336 FRACTURES AND DISLOCATIONS 

directly backward so that the zygomatic surface encroaches on the 
space normally occupied by the temporal muscle and coronoid 
process. The condition is rare but when present may interfere 
with the function of the lower jaw. 

The infraorbital canal runs close to the plane of suture between 
the superior maxilla and the malar, and w^hen the latter is im- 
pacted into the former w^e may have injury to the nerves contained 
wdthin the canal; namely the antero-superior dental, the middle 
superior dental, and the fibres wdiich are later continued into the 
terminal branches. Accordingly, disturbances in sensation may 
occur in the upper teeth and gums as far back as the second bi- 
cuspid (inclusive) and in the terminal branches of the infraorbital 
on the face. 

The subcutaneous tissue covering this region is loosely cellular 
and devoid of fascia, thus permitting of pronounced and rapid 
swelling which is so frequently a hindrance to diagnosis. 

The muscles attached to this bone are three in number; two of 
them, the zj^gomaticus major and minor are muscles purely of 
expression, and hence disturbances in their function Avill be diffi- 
cult to recognize ; but the masseter, attached to the postero-inf erior 
border, is a muscle of mastication, and disturbance in this func- 
tion is readily detected. 

The malar bone is sometimes normally divided into two parts 
by a horizontal suture, which anomaly should not be mistaken for 
fracture during operation or w^hile exploring wounds. 

The postero-superior border of the bone is continuous with the 
temporal crest of the frontal above, with the upper border of the 
zygoma below and has the heavy temporal fascia attached to it 
throughout its extent. The antero-superior border forms the lower 
and outer margin of the orbit and in this position is easity pal- 
pated, as is the postero-inferior border of the bone. 

Etiology. — Fracture of the malar, like fracture of the nasal 
bones, is the result of direct violence, such as falls and blows on 
the face. It requires a much greater degree of violence, how^ever, 
to fracture the malar than' it does the nasal bones. 

Symptoms. — Pain is a constant element, while mobility and 
crepitus are more often absent than present. Swelling is usually 
rapid and pronounced, and ecchj^mosis about the eye common. 
The patient will usually give a history of severe trauma and may 
present a number of variable sj^mptoms according to degree and 



FRACTURES OF MALAR BONE AND ZYGOMATIC ARCH 



337 



direction of the displacement. If the anterior and middle dental 
branches of the superior maxillary nerve have been injured there 
mav be considerable pain, numbness and tingling of the gums 




Fig. 473. — Fracture of the left malar bone a few minutes after injury. Note the 
swelling about the left eye and the way the examining finger sinks into the left side of 
the face. A number of air blebs were seen beneath the conjunctiva twenty-four hours 
later, the air having gained entrance to the tissues through the antrum. 




Fig. 474. — Fracture of left malar bone twenty-four hours after injury. Note how 
the finger sinks into the patient's face beneath the swollen, ecchymotic eye. A portion 
of the infraorbital ridge is depressed and may be palpated. 

and teeth of the affected side as far back as second bicuspid (in- 
clusive). Fractures of the zygomatic arch or a backward dis- 
placement of the malar may be accompanied by disturbances in 



338 FRACTURES AND DISLOCATIONS 

function of the mandible. There may be pain in the affected side 
on mastication; in severe cases the patient may be totally unable 
to move the jaw. The characteristic symptom will consist of a 
depression of the malar or zygomatic arch with a corresponding 
flattening of the cheek; this symptom however may be masked by 
swelling, within a few minutes of the injury, and unless a care- 
ful examination is made at the time, the true condition may be 
overlooked. Conjunctival ecchymosis is usually present and, in 
some cases, conjunctival emphysema. 




Fig. 475. — Fracture of the posterior portion of the malar and the anterior end 
of the zygoma on the left side of the face. Note how the examining finger sinks into 
the depression and compare it with the finger on the corresponding point on the un- 
injured side. Eye swollen shut and conjunctiva blood-shot. Photograph a few min- 
utes following the injury. 

Diagnosis. — If the swelling is not great the examination and 
diagnosis should be easy. The deformity Avhich results from the 
depression of the malar or zygomatic arch is masked during the 
acute stage by the swelling, and unless a careful examination is 
made to determine the condition and position of the underlying 
bone we may learn subsequently to our chagrin what the real de- 
formity is, after the swelling has subsided and union has taken 
place. Inspection alone, in these cases, is valueless since the vis- 
ible symptoms are the same as seen in ordinary ''black eye" 
(ecchymosis and swelling). We should therefore carefully pal- 
pate the parts to determine the position of the underlying bone. 
In most cases, continued pressure with the finger will displace the 
intracellular inflammatory fluids sufficiently to allow the surgeon 



FRACTURES OF MALAR BONE AND ZYGOMATIC ARCH 339 

to satisfactorily appreciate the conditions present, and to compare 
them with the facial contour of the uninjured side. The two 
sides can best be compared by standing behind the patient and 
palpating- both bones simultaneously with the thumb and index 
finger of each hand (see Fig. 473). The presence of depression 
can be determined by placing the two index fingers over the prom- 
inent portion of the cheeks, and comparing the two sides; suffi- 
cient pressure on the injured side should be made to allow the 
finger to sink in, in order that we may eliminate the swelling 
which is otherwise misleading. The orbital, temporal and masse- 
teric borders may be palpated and the position of the bone thus 
determined and compared. The conjunctiva should be examined 
for the purpose of detecting ecchymosis or emphysema ; the former 
is b}^ no means pathognomonic, but the latter is the result of air 
having passed from the nasal cavity into the conjunctiva, which 
is impossible if the bones of the face are intact. 

Treatment. — The first indication in the treatment of these cases 
is to counteract the local effects of trauma and to relieve pain 
when severe. The inflammatory reaction can be maintained at 
the minimum by the use of the ice-bag for the first twelve to 
twenty-four hours. In most cases, an attempt to correct the de- 
formity is purely for cosmetic reasons, and in considering this 
element w^e must take into consideration the surroundings of the 
case. 

For example: deformity resulting from depression of the malar 
may be deemed an extremely important matter in the case of 
the young society woman, while, on the other hand, the average 
laborer would not consider for a moment the trouble, time and 
expense necessary for the correction of the disfiguration which in 
no way interferes with his earning capacity. When no attempt 
is made at correcting the displacement the case resolves itself 
firstly, into the control of local reaction ; secondly, allowing nature 
to unite the impacted fragments; and thirdly, the treatment of 
accompanying wounds when present. If the fracture is compound 
as a result of direct violence the wound should be cleansed and 
the edges approximated according to general surgical principles 
as applied to the treatment of wounds and compound fractures. 
When complications exist, such as interference with the action of 
the jaw, or extreme and prolonged pain in the region of the 
superior dental nerves, operation is indicated. 



340 FRACTURES AND DISLOCATIONS 

Operative Treatment. — Operation may become necessary for 
cosmetic reasons or for the alleviation of complications such as 
the interference with the action of the jaw; the type of operation 
will depend to some extent on the reasons for which it is under- 
taken. When performed for cosmetic reasons only, open incision 
should be avoided, because of the resultant scar. In these cases, 
the bone may be approached from the mouth through an incision 
parallel with the alveolar process and opposite the malar process 
of the superior maxilla, the thick part of which may be felt oppo- 
site the first molar. This incision is carried up under the cheek 
until the malar is exposed, after wiiich it is pried back into posi- 
tion and the incision closed. Another method is that of making 
a small incision through the skin, drilling a hole in the face of 
the malar and inserting a screw, by which means the bone may 
be raised and replaced. Any modification of an intraoral opera- 
tion should be conducted with due consideration for asepsis and 
followed by frequent douchings. Deformity has been successfully 
corrected by the subcutaneous injection of paraffin, though the 
method is somewhat questionable. The difficulty with operative 
treatment is not so much a ciuestion of replacing the bone as it 
is of maintaining it in its original position, and the reason for 
this difficulty is explained by the loss of bony tissue which takes 
place in impaction. In other words it is not difficult to reduce 
the deformity, but we do not have the supporting process intact 
to maintain reduction after the impaction has been broken up. 
In Lothrop's operation the ^ bone is approached through the mouth 
as previously described, the depression corrected and the antrum 
packed with gauze to maintain the malar in its elevated position. 
The gauze is left in place for four or five days. The cavity is 
packed a second time — if there is tendency toward a recurrence 
of the deformity — and left for a second period of four or five days. 
The danger in this operation consists of infection, which is 
favored by allowing the packs to remain during the period indi- 
cated. Some of the more recent work done with bone transplants 
would suggest the use of bone wedges taken from the tibia to 
support the malar in its raised position, the wound being closed 
without drainage. Fracture and depression of the zygomatic arch 
call for reposition of the fragments; this is most satisfactorily 
accomplished by means of a direct incision exposing the bone. 
If the incision is made parallel to, and a short distance above the 



FRACTURES OF MALAR BONE AND ZYGOMATIC ARCH 



341 



{ 


k% 


1 


^:'^im^ 


r 

Si::.: 


m 





Fig. 476. — Depressed fracture of right malar of two years' standing. Note hollow 
under patient's right eye. Deformity moderate. Compare this deformity with that 
seen in case shown in Figs. 477 and 478. 




Fig. 477 



Figs. 477 and 478. — Old depressed fracture of the right malar with pronounced de- 
formity. Note the flattened cheek v/hich is best appreciated in profile. Patient gives 
history of severe direct violence with practically no treatment following same. 



342 FRACTURES AND DISLOCATIONS 

arch we can frequently replace the bone and still have the resultant 
scar in a position which will be covered by the hair after recovery 
is complete. Care should be taken to accurately approximate the 
temporal fascia before closing the wound. Sensory disturbances 
in the course of the dental nerves will usually clear up, but when 
severe may call for operative intervention to relieve the pressure. 
Pain in the terminal branches of the infraorbital nerve can some- 
times be controlled by a hypodermatic injection of alcohol into the 
nerve as it emerges from the infraorbital foramen. 

After-Treatment. — The after-treatment in the ordinary case 
consists of the avoidance of additional trauma, and allowing 
Nature to unite the fragments. No retentive apparatus is neces- 
sary and dressings are not called for except in compound cases. 
The mouth and nose should be kept clean by the use of antiseptic 
douches to avoid the possibility of infection by way of the antrum. 

Prognosis. — Deformity is a common result of fracture of the 
malar, and even though operative intervention may reduce the 
displacement it is rarely possible to return the fragments perfectly 
to their original positions. Neuralgias maj^ follow the condition, 
but usually subside within a few months even if allowed to go 
untreated. Interference with the action of the lower jaw follow- 
ing depression of the arch is a condition which has been followed 
by recovery of function even in cases where no treatment has been 
employed. 



CHAPTER XXVII. 

FRACTURES OF THE SUPERIOR MAXILLA. 

Surgical Anatomy. — The superior maxilla may be considered the 
shell which forms the wall of the antrum of Highmore, and from 
this shell we have projecting in various directions, processes of 
bone which articulate with the adjoining bones of the face and 
cranium. The different regions into which these processes project 
and their several functions render the subject of fracture of this 
bone diverse. 

The "^lasal process extending upward, inward and backward, ar- 
ticulates with the nasal, lachrymal, frontal and ethmoid bones, and 




Fig. 479. — Superior maxilla. N., nasal process; M., malar process; O., orbital 
process; I.F., infraorbital foramen; A. A., alveolar process. (See Fig. 471.) 

enters into the formation of the nasal cavity, the orbit, the anterior 
ethmoidal cells and the lachrymal canal. Fracture of this process 
is associated with fracture of the nasal bones and for surgical 
purposes is to be considered under fractures of the nose. 

The alveolar process is thick and arched and is hollowed out into 
sockets corresponding in number, depth and width to the sixteen 
upper teeth. A portion of the alveolar arch is not uncommonly 
fractured in the extraction of teeth, but the injury is not, as a 
rule, of serious import provided the line of fracture is confined 
to this process. 

343 



344 FRACTURES AND DISLOCATIONS 

The malar process is thick, composed of a heavy tissue, supports 
the malar bone and sustains most of the impaction when the malar 
is driven into the face. It is therefore best considered with frac- 
tures of the malar. 

The palatal process forms the greater part of the roof of the 
mouth and in this position is rarely subject to injury. It is some- 
times, however, fractured by falls on objects held in the mouth, 
and is not infrequently the site of suicidal gunshot injury. 

Fracture of the hody of the hone may occur from blows on the 
face especially in instances in which the malar is impacted into its 
substance. Fractures of the body involve the antrum of Highmore 
and are therefore compound connecting with the- outer air through 
the nasal cavity. In comminuted fractures, especially gunshot in- 
juries, the fragments may be driven into any adjoining cavity 
(orbit, nasal cavity, zygomatic fossa, temporal fossa, mouth) or 
they may be displaced into the antrum itself. We may have a 
vertical line of fracture separating the bones of the two sides, or 
a horizontal fracture disarticulating the maxilla from the frontal. 
Another form" of horizontal fracture situated at a lower level, 
separates the alveolar and palatal processes from the rest of the 
bone. Such fractures are necessarily the result of severe direct 
violence, such as a fall from a height or a kick from a horse. The 
relation of the antral cavity to the surface of the bone, and the 
manner in which the palate, inferior turbinate, and ethmoid close 
in the opening between the antrum and the nose are of surgical 
importance as regard drainage in cases of infection. The antrum 
may be entered by way of the nose, through the canine- fossa, or 
by extraction of the first or second molars. The circulation in the 
region of the face is extremely free, accounting for the rarity with 
which necrosis occurs in the fragments and the manner in which 
loosened teeth regain their solidity. A considerable portion of 
the superior maxilla is covered with mucous membrane, which is 
usually torn if the fracture involves this region; we shotild there- 
fore examine the nasal and oral cavities in making a diagnosis. 

Symptoms. — Deformity is very variable and may be entirely 
masked by the swelling which is likely to be pronounced and fol- 
lows the injury rapidly. The most common displacement consists 
in depression of the fragments, the face being '' driven in" to a 
greater or less extent, in the region of the injury. Hemorrhage 
from the nose or mouth is prone to occur, and emphysema is some- 



FRACTURES OF SUPERIOR MAXILLA 



345 



times seen as a result of air having been forced into the tissues 
from either the oral or nasal cavities. Depression in the region of 
the antrum is most common. Mobility and crepitus are variable 
and their absence should not lead us to exclude fracture. Loss of 
alignment in the teeth and mobility of a section of the alveolar arch 
are usually present when the fracture involves this process. The 
symptoms in general will vary greatly according to the region of 
the bone involved and the associated injury of the soft part. We 
sometimes see cases in which the face is so severely crushed that 
it is no longer a question of which of the facial bones is fractured 
but, — have any escaped? 




Fig. 480. — Fracture of superior maxilla. Patient injured in automobile wreck. 
Fracture extends through, alveolar process, body of bone and through the orbital 
process. Posterior fragment displaced downward as may be seen by the disturbed 
dental alignment. 



Diagnosis. — The upper jaw is examined in a manner similar to 
the malar. The outline of the upper portion may be palpated 
through the face and its two sides compared. The lower portion 
of the bone and the teeth may be examined through the mouth, and 
the lateral wall of the nasal cavity inspected through the nostril. 
Mobility may rarely be elicited by making pressure on the face in 
various direction. Crepitus is likewise an uncommon symptom. 

Treatment. — The treatment of fracture of the superior maxilla, 
like the symptoms, varies according to the region of the fracture. 
Fracture of the nasal process is treated similarly to fracture of the 
nasal bone, and is included under that heading. Fracture of 



346 FRACTURES AND DISLOCATIONS 

the malar process is a condition very similar to so-called fracture 
of the malar, and is treated in a like manner. Fracture of the 
body of the bone frequently calls for some method of elevating 
the depressed fragment, and this may often be accomplished 
through the mouth, thus avoiding a scar of the face. Fracture of 
the superior maxilla is very commonly associated with severe lac- 
erated wounds of the face, and when such is the case we have the 
wound to deal with in addition to the fracture itself. The vitality 
of the tissues is high on account of the free circulation, and ac- 
cordingly it will seldom be necessary to remove fragments of bone 
or to trim away torn tissue unless manifestly devitalized. Lac- 
erated wounds of the face should be freely washed with normal 
salt solution in order to remove infectious material which has been 
driven into the tissues, and wounds of the mucous membrane com- 
municating with the fracture through the mouth should be fre- 
quently and freely irrigated in order to avoid subsequent infection. 
Fracture of the alveolar arch is to be treated according to the re- 
quirements of each individual case. When there is no tendency 
toward displacement of the fragments the chief indication is that 
of cleansing with a mild alkaline solution. If there is displace- 
ment of teeth and disturbed occlusion through loss of alignment it 
may become necessary to hold the fragments in position by wiring 
the teeth or by means of an aluminum dental splint as described 
in the treatment of ''Fracture of the Lower Jaw" (page 357). 
Separation of the two superior maxillae may also be immobilized 
in the same manner. Openings through the palatal process should, 
except in cases of simple fissure, be protected from the mouth dur- 
ing the process of healing by a hard rubber plate. In gunshot 
injuries, the area of fracture may be protected from contamina- 
tion by food, and the nasal and oral cavities separated in this 
manner. 

Operative Treatment. — Operative treatment is indicated in 
severe compound cases. It will be impossible, however, to laj down 
any hard and fast lines of procedure, since the needs of each and 
every individual case will' vary, and the surgeon will find it neces- 
sary to meet the demands of the case in hand. 

After-Treatment. — The chief indication of after-treatment will 
be to keep the parts clean, prevent infection and allow nature to 
unite the fragments. In the presence of infection we should see to 
it that the antrum is freely drained; this may be accomplished by 



FRACTURES OF SUPERIOR MAXILLA 347 

the extraction of the first or second molar or by perforating the 
anterior wall of the antrum above the roots of these teeth. The 
antrum may also be entered and drained through the inferior or 
middle meatus; when the opening is made through the inferior 
meatus it may be necessary to previously remove the inferior 
turbinate. During the earh^ part of the after-treatment the nose 
should be irrigated three to four times daily and the oral cavity 
should receive equally careful attention. 

Prognosis. — Union usually takes place in from six weeks to two 
months. Prognosis as to life is good except in severe crushing 
injuries of the face in which shock is great, and associated injuries 
of the skull and brain probable. The prognosis as to deformity 
is frecjuently not good in fracture of the body of the bone. Frac- 
ture of the nasal process can usually be treated without subsequent 
deformity. Fracture of the malar process is not so favorable in 
this respect. 

The presence of infection renders the prognosis worse but if 
proper treatment be established without delay and efficient drain- 
age and lavage maintained the outcome should in most cases be 
good. In fracture of the alveolar process small sloughs of bone 
may require removal but this does not signify that the ultimate 
outcome will not be good. 



CHAPTER XXYIII. 

FRACTUKES OF THE LOWER JAW. 

Fracture of the lower jaw is a common injury, constituting nearly 
four percent of all fractures, and, since the bad results so often 
seen are due to mechanical and anatomical causes, it is evident that 
an intimate understanding of the anatomy of the parts is essential 
to the successful treatment of this fracture. 

Surgical Anatomy. — The inferior maxilla or mandible is the 
largest and strongest bone of the face and, Avith the exception of 
the nasal bones, is most frequently fractured. It is composed 
of the body, ramus, and two processes ; the coronoid and condylar. 




Fig. 481. 

Figs. 481 and 482. — Two views of the mandible. 
Coronoid process; A., Angle of jaw; S., Symphysis. 



Fig. 482. 

Con., Condyloid process; Cor. 



Its position is very much exposed to violence, but, on the other 
hand, there are numerous elements which render the bone capable 
of withstanding considerable trauma without fracture. Its weight 
is considerable and the structure heavy, its mobility great, and the 
buffer-like action of the interarticular fibro-cartilage of the tem- 
poro-maxillary articulation serves to maintain the integrity of the 

348 



FRACTURES OF LOWER JAW 349 

bone in the presence of a blow. In addition the horseshoe shape 
of the body imparts a certain spring to the bone which is pro- 
tective. The manner in which the fragments of the body are dis- 
placed will depend on the muscles attached to the bone. To the 
external surface in the region of the chin, we have the levator 
menti, while along the external oblique line are seen the attach- 
ments of the depressor labii inferioris, depressor anguli oris and 
platysma myoides. These muscles with the exception of the last 
named extend upward toward the chin, are small, and of minor 
importance in displacements. The buccinator is attached to the 
alveolar margin opposite the three molars. The masseter, a pow- 
erful muscle, occupies the external surface of the ramus, and pulls 
in an upward direction. The coronoid process is taken up by the 
insertion of the temporal muscle, which has a displacing action 
similar to that of the masseter. The internal surface of the body 
has the mylo-hyoideus arising from the mylo-hyoid ridge, and the 
genial tubercles have attached to them the genio-hyoglossus and 
the genio-hyoideus. One of these muscles enters directly into the 
formation of the tongue, while the remaining two are attached to 
the hyoid bone and when their anterior bony attachments are dis- 
placed backward, as is sometimes the case in bilateral fractures, 
we have backward falling of the tongue. This condition, espe- 
cially during unconsciousness, may cause asphyxia if the tongue 
is not pulled away from the epiglottis by direct forward traction 
on the tongue itself, or by drawing the displaced fragment for- 
ward. To the posterior surface of the symphysis below the genial 
tubercles we have the diagastric muscles attached on either side. 
The pull of this pair of muscles is downward, backward and 
slightly outward. The superior constrictor of the pharynx has an 
attachment internal to and behind the last molar. Tlie internal 
pterygoid is attaclied to the deep surface of the ramus in the 
region of the angle, while the external pterygoid is attached to 
the internal surface of the condylar process. These muscles have 
a lateral displacing action in fractures of the lower jaw ; the com- 
mon inward displacement of the posterior fragment is largely due 
to the unopposed action of the internal pterygoid. The temporal 
and masseter produce the usual upward displacement of the pos- 
terior fragment. As a result, therefore, of the combined action of 
these muscles the posterior fragment, in fractures of the bod.y, 
will usually be displaced upward and inward (see Figs. 485 to 



350 FRACTURES AND DISLOCATIONS 

489). Accordingly in the correction of tlie deformity and during 
the subsequent immobilization of the fragments it is the displacing 
action of these muscles with which we have to contend. 

In fracture of the body of the bone wide displacement of the 
fragments is usually prevented by the line of fracture passing 
through the attachment of some of the muscles, especially the mylo- 
hyoideus which is, as a rule, attached to both sides of the line of 
fracture. The masseter and internal pterygoid tend in like man- 
ner to limit the separation of fragments when the ramus is frac- 
tured. 

On the internal surface of the ramus we have the inferior dental 
foramen for the passage of the inferior dental nerves and vessels 
which pass through the substance of the bone supplying the teeth 
of the lower jaw. Injuries to these structures sometimes occur, 
though not as commonl}^ as might be inferred. The long root of 
the canine and the mental foramen are both considered elements 
of weakness in the structure of the inferior maxilla; it is in this 
region that fracture most frequently occurs. The mucous mem- 
brane is torn in most cases of fracture o£ the body and accordingly 
the break is usually compound. 

It should be remembered that the facial artery passes onto the 
external surface of the body of the bone just anterior to the antero- 
inferior angle of the masseter muscle. From a point behind the 
posterior border of the ramus of the jaw we have the beginning 
of the pes anserinis, comprising the motor fibres running to the 
various muscles of the face. Stenson's duct runs directly forward 
from the parotid gland and empties opposite the second upper 
molar. The positions of the artery, nerve and duct are of impor- 
tance when the fracture is accompanied by wounds of the face. 
In fractures of the condylar process the upper fragment may be 
displaced forward and inward by the action of the external 
pterygoid pulling in the direction of the external pterygoid fossa. 
Fracture of the coronoid is extremely rare, occurring only in con- 
junction with fracture of other bones in this region, such as the 
zj^gomatic arch. It is said however to have been broken as a result 
of muscular action. 

Etiology. — Direct violence is responsible for most fractures of 
the inferior maxilla. Fractures due to indirect violence are seen 
in instances in which the symphysis has been fractured by lateral 
compression, the condyle broken off by a blow on the chin and 



FRACTURES OF LOWER JAW 



351 



in avulsion of the eoronoid tubercle, as a result of muscular 
action. 

Symptoms. — The symptoms of fracture of the inferior maxilla 
will depend upon the followiug conditions: the region of the break, 




Fig. 483. — Fracture of mandible at symphysis. Mobility apparent on palpation or 
when patient attempts to speak. Arrow indicates line of fracture. Right central 
incisor loose. 




Fig. 484. — X-ray plate of same case showing line of fracture. 



the degree of the causative trauma, and the displacing action of 
the muscles attached to the fragments. There will be swelling, 
tenderness, pain, deformity, abnormal mobility, loss of function 
and crepitus. Swelling is usually pronounced and follows the in- 
jury rapidly. Tenderness and pain are present in the region of 



352 



FRACTURES AND DISLOCATIONS 




Fig. 485. — Fracture of the lower jaw just anterior to th.e right canine. Note the 
upward displacement of the posterior fragment. The dark shadow between the lower 
teeth and lip is blood which is coming from the fractured surfaces and torn mucous 
membranes. Photograph taken shorUy following accident. Arrow indicates line of 
fracture. 




Fig. 486. — Fracture of lov-er jaw at the point indicated by the arrow. Note loss of 
alignment of the lower teeth. 



FRACTURES OF LOWER JAW 



353 



the break, and are increased by any attempt at using the jaw. 
The deformity accompanying the usual fracture in the neighbor- 
hood of the canine is characteristic : the posterior fragment is dis- 
placed upward and inward, and loss of alignment in the teeth 
(except in edentulous cases) is apparent upon examination. Frac- 
ture behind the last molar, in the ramus or in the condyle is rarely 
seen, but when it does occur the deformity is less easily detected. 




Fig. 487. — Fracture of the lower jaw about twenty-four hours following injury. 
Line of fracture passes between the lateral incisor and canine on the left side. Note 
how the posterior fragment is raised. In this instance the fracture is a little oblique 
so that the fractured surfaces have engaged in such a manner that the posterior frag- 
ment is prevented from the usual inward displacement. 



The anterior border of the ramus, however, may be palpated from 
within the mouth with little difficulty even in cases where swelling 
of the face is pronounced enough to prevent opening the mouth. 
In such cases the finger is passed between the cheek and the teeth, 
and carried back far enough to determine the outline of the an- 
terior margin of the ramus. In addition to direct palpation we 
may detect abnormal mobility b}^ placing the fingers of one hand 



354 



FRACTURES AND DISLOCATIONS 



on the ramus of the jaw externally, while the opposite hand moves 
the chin. Fracture in the region of the symphysis is readily de- 
tected by inspection and palpation. The functions of mastication 
and articulation are interfered with from the first and on account 
of the subsecjuent inflammatory reaction become progressively more 
pronounced in the earlier stages of the condition. Crepitus can, 
in most cases, be elicited, but is usual! v not necessarv in diaR'nosti- 




Fig. 488. — Fracture of lower jaw immediately following injury. Line of fracture 
passes between the second bicuspid and the first molar on the right side. Note how the 
posterior fragment is displaced inward and remains raised when the mouth is opened as 
a result of the unopposed actions of the right temporal and niasseter muscles. This 
is the usual deformity and should be particularly guarded against in the treatment. 
If the defoi'mity is allowed to go uncorrected there will result faulty dental alignment, 
malocclusion and the chin will be displaced toward the injured side. The further 
back the line of fracture the greater the leverage of the displacing muscles. 



eating the condition. AVe should only attempt to produce crepitus 
after other means of ascertaining the presence of fracture have 
failed; the less the fragments are manipulated the better it is for 
the patient. The usual case presents a characteristic pictui-e : the 
patient suffering considerable local pain presents himself for treat- 
ment because of severe injury sustained in the region of the jaw, 
one side of the face shows swelling, and ma}^ or may not be accom- 
panied by a wound. The lips and teeth are slightly separated, the 



FRACTURES OF liOWER JAW 



355 




Fig. 489. — Fracture of the right side of mandible about six weeks after injury 
and after union had taken place. First seen by author at this time. In this case the 
inward displacement of the posterior fragment caused by the internal pterygoid muscle 
has been allowed to go uncorrected and malocclusion and displacement of the chin 
toward the injured side has resulted. The displacement of the chin is best appre- 
ciated when the jaws are closed. 





Fig. 490. — Fracture of the luandible Ijeliind Uie hist molar on the left side. Pos- 
terior fragment displaced upward so that the fractured surface may be seen. Photo- 
graph retouched. Anterior surface of raised posterior fragment outlined to direct atten- 
tion to its position. Reduction accomplished through incision at the angle of the jaw and 
wiring of the fragments. Case seen with Dr. H. R. McGraw. 



356 



FRACTURES AND DISLOCATIONS 



patient is unable to talk with any degree of distinctness, saliva 
drools from the month, and on inspecting the teeth we find the 
characteristic upward and inward displacement of the posterior 
fragment with loss of dental alignment. ]\Ianipulation of the 
parts increases the suffering. If the case has been allowed to go 




Fig. 491. — RontgenogTam of case siiii 
loosened and displaced last n;olar. 



the one sho-wn in Fig. 490. Note the 



untreated for a few da^'s we have added to the above symptoms 
those of putrefactive changes within the oral cavity : there is a 
foul, characteristically offensive odor, and pus may be mingled 
with the saliva. 

Diagnosis. — The presence of fracture can almost always be deter- 
mined by palpation and inspection. The diagnosis is based on the 
presence of the symptoms just enumerated. The condition is usu- 
ally so easy to recognize that it is common for the patient to make 
the diagnosis before he is seen by the surgeon. Fracture of a 
portion of the alveolar arch accompanying the extraction of teeth 
sometimes goes unrecognized. Probing the socket will usually de- 
termine the condition if fragments are present. Fracture of the 



FRACTURES OF LOWER JAW 357 

ramus or condyle in some cases calls for the use of the X-ray, to 
clear up the diagnosis. 

Treatment. — Fracture of the inferior maxilla is a condition 
which has been treated from time immemorial with poor or in- 
different success ; it is, however, only within recent years that more 
accurate and satisfactory results have been attained, due to the 
introduction of improved methods, such as the intraoral splint in 
its various modifications, wiring the jaws together, and direct op- 
erative procedures. Eeduction of the displacement is usually easy 
but the difficulty arises when we come to immobilizing the frag- 
ments. The different methods employed all attempt the attain- 
ment of two ends : firstly, the reduction and permanent cor- 
rection of the deformity, and secondly, the prevention of infection. 
The various principles followed and appliances devised to accom- 
plish these results are too numerous to mention; we will consider 
under the following headings only those which have been found 
most satisfactory. 

1. Simple binding of the lower jaw against the upper by 

means of the fourtailed bandage. 

2. Some form of interdental splint and the fourtailed band- 

age. (Gunning.) 

3. Dental splint with arms attached for counter-pressure be- 

neath the jaw\ (Kingsley, Acldand, Matas.) 

4. Dental splint cemented to the teeth. (Heath.) 

5. Wiring the lower to the upper teeth. Oliver's method. 

Simple wiring, Angle bands with wire. 

6. Securing the fragments by means of wiring the teeth of the 

lower jaw. 
Wiring of teeth adjacent to fracture. Hammond's wire 
splint, Angle bands with connecting bar. 

7. Operative treatment. Direct wiring or plating of the 

fragments. Bone transplantation. 

All of these methods have their points of advantage and their 
drawbacks, but from among them we are enabled to select the one 
best suited to the case in hand. 

1. Simple Mnding of the lower jaw to the upper is the oldest 
method known and in the presence of modern facilities is only 
mentioned to be condemned. As an emergency method, however, 
it has its uses and will tend to keep the fragments at rest and more 



358 FRACTURES AND DISLOCATIONS 

or less opposed until some more accurate means can be employed. 
Its disadvantage consists in its persistent tendency to loosen, which 
may, to some extent, be corrected by strips of adhesive plaster 
placed over tlie cloth after the bandage has been applied. The 
dressing may be tightened in this manner as often as it becomes 
loose during the after-treatment. A fourtailed bandage may be 
made entirely of adhesive as follows : a three-inch strip of adhesive 
long enough to encircle the head (from the chin to the lambda) 
one and one-half times, is split on either end leaving a solid piece 
of about two inches in the middle. This middle piece is applied 
to the chin, the head having been previously covered b}" a layer 
of gauze. The two lower tails are carried upward and slightly 




Fig. 492. Fig. 493. 

Fig. 492. — Four-tailed bandage made with adhesive plaster. Head has been cov- 
ered with gauze to prevent adhesive coming in contact with hair. 

Fig. 493. — Same with superfluous gauze cut away. Dressing completed. More 
convenient and neat than either the ordinai^j- four-tailed bandage or the plast-er 
bandage. 

backward, and attached to the gauze with sufficient traction to 
secure the lower jaw against the upper. The upper pair of tails 
is then carried backward to meet and overlap in the occipital 
region. (Figs. 492 and 493.) After this has been done the super- 
fluous gauze is trimmed away and we have a dressing much 
more secure than . the ordinary fourtailed bandage. During the 
after-treatment the dressing may be tightened by additional strips 
of adhesive without disturbing the parts. In securing the lower 
jaw to the upper in this manner, extreme care must be talcen to 
keep the month clean during the after-treatment. The approxi- 
mation of the lower teeth to the upper insures perfect occlusion, 
but the employment of external pressure alone is too insecure to 



FRACTURES OF LO^YER JAW 



359 



be relied upon and must be accompanied by some additional 
method of internal fixation. 

2. Interdoital splint wifli fourtailed bandage. 

Yarions materials have been used for interdental splints but none 
have been fonnd as serviceable and satisfactory as vulcanized rub- 
ber. The production of the hard rubber interdental splint (Gun- 
ning) requires a certain amount of laboratory technique, familiar, 
as a rule, onh^ to the dentist ; when such services can be obtained 
by the surgeon the treatment is rendered much easier. In making 
a vulcanite interdental splin^t it is necessary first to take impres- 




Fig. 494. — Intei'dental splint of vulcanite Avitli opening for feeding of liquids. 

sions of the upper and lower dental arcades. These impressions 
may be taken in wax, dental composition, or plaster. After the 
impressions have been taken a counter-impression of each is made 
with plaster of Paris. These counter-impressions of the upper 
and lower teeth are next properly trimmed and mounted respec- 
tively on the upper and lower arms of a dental articulator. Then 
by means of a fine saw the lower cast is cut in the region of the 
fracture, and the portions of the cast representing the fragments 
are brought back into alignment. The reduction is next tested 
by closing the articulator, thus bringing the low^er teeth against 



360 FRACTURES AND DISLOCATIONS 

the upper. Further corrections must be made when necessaiy for 
the production of perfect occlusion. "When proper occlusion with 
the upper teeth is produced we have the exact x^osition which 
should be occupied by the fragments of the mandible. The sawed 
portions of the lower cast are then fixed with plaster in the cor- 
rected position, after which the articulator is opened until the 
casts are in the same relative positions which the upper and lower 
jaws should occup}^ during the after-treatment. The interval be- 
tween the upper and lower dentures is then filled in with bees- 
wax and worked out in detail of the size and proportion desired 
for the interdental splint. Openings in the splint for the admis- 
sion of food must be provided for. The two ciasts together with 
the intervening wax are next removed, being cut in such a manner 
that only that portion of each cast representing the teeth and gums 
is included. The two cut-down casts with intervening wax form 
are then placed in a vulcanizing flask (their relations being un- 
disturbed), and plaster poured into the flask until it rises half 
way up the wax form. This is allowed to set and dry after which 
the surface is shellacked and covered Avith powdered soapstone. 
The second half of the mould is then made by pouring in plaster 
which is alloAved to set ; then the two moulds are separated and 
the wax melted out w^th hot water. AYhen the wax is removed 
we have a cavity in each mould which when taken together cor- 
respond to the built-up wax form which was made on the articu- 
lator. These cavities are then packed wath dental rubber, the 
moulds put together again and placed in a vulcanizing flask, the 
process now^ being the same as that employed in making the ordi- 
nary dental plate. When vulcanization is complete the splint is 
removed for finishing and polishing, after which it is ready for 
use. This form of splint is particularly useful when other meth- 
ods w^ould be unsatisfactory because of partial or complete loss of 
teeth. When the patient wears a complete set of false teeth these 
may, by proper alteration, be used as a splint during the after- 
treatment of the fracture, or a splint may be made by impression 
from that portion of the plate coming in contact with the gums. 
Wedges of dental composition or gutta-percha may be used be- 
tween the teeth as splints. They are much more easih^ applied 
but are not as satisfactory as the vulcanite splint, and do not 
alloAv the drinking of hot liquids while in use. 

8. Denial splint with arms for counter-pressure 'beneath the chin. 



FRACTURES OF LOWER JAW 



361 



• — The chief representatives under this heading are the appliances 
devised by Kingsley, Ackland and Matas. 

Kingsley's appliance is a moulded splint conforming with the 
irregularities of the inferior dental arcade and holds the frag- 




Fig. 495. — Metal dental splint with arms for counter-pressure by means of bandages 
passing beneath the lower jaw. 




Fig. 496. — Vulcanite splint with arms for counter-pressure. 



ments in reduction by means of counter-pressure beneath the chin. 
Two lateral arms are secured to the splint which emerge through 
the mouth and afford attachment laterally for bandages passing 
under the jaw. The body of the splint may be made of various 



362 FRACTURES AND DISLOCATIONS 

materials, and the technique of production will vary accord- 
ingly. 

Ackland's splint consists of a metal gutter partly filled with 
gutta-percha which when softened takes the imprint of the lower 
teeth. The intraoral portion of the apparatus is held in position 
by means of clamps which make counter-pressure beneath the chin. 

The Matas splint (see Fig. 497) consists of an adjustable clamp 
to be applied to the lower jaw. The intraoral arm carries a block 
tin form which is trimmed and bent to fit the teeth while the 
lower arm carries a perforated, adjustable, aluminum chin piece 
for counter-pressure. The intraoral block tin form is notched to 
facilitate bending and fitting to the teeth ; this gutter may be filled 




Fig. 497. — The Matas splint. An excellent apparatus for the treatment of cer- 
tain fractures of the lower jaw. This splint is adjustable and is supplied with differ- 
ent sizes of chin plates and dental splints. 

with gutta-percha or dental composition to obtain more firm and 
accurate contact between teeth and splint. Tliis splint will give 
very satisfactory results in the usual fracture of the body and may 
be applied with little difficulty. 

The three splints just described together with the one following 
have the common advantage of allowing motion of the lower jaw 
during the after-treatment. Soft food may be masticated after the 
first few days and the patient has litth? difficulty in talking. The 
splint possessing these advantages in the greatest degi-ee is the 
following : 

4. Dental splint cemented to the teeth. (Heath.) 
This splint is made of metal according to principles similar to 
those just described in producing the vulcanite splint. The dif- 



FRACTURES OF LOWER JAAV 



363 




Fie. 498. — Metal dental splint for cementing to the lower teeth. 




Fig. 499. — Same splint with the teeth in occlusion. In placing this splint in posi- 
tion the greatest care should be exercised to see that both splint and teeth are thor- 
oughly dry, as otherwise the cement will not hold. Tlie mucous surfaces are walled 
away with sheet cotton. 



364 



FRACTURES AND DISLOCATIONS 



ference in material, however, will necessitate an altered laboratory 
technique, which is as follows : plaster casts of the two dental 
arcades are made and the deformity in the lower one corrected 
as described under heading No. 2, page 359. The cast of the 




Fig. 500. — Edmund's forceps for clamping metal splint to the bases of the teeth. 
Slipping of the instrument and injury to the gums and alveolar process is prevented 
by the set-screw between the jaws which engages the crown of the tooth. 

lower denture is built up so as to do away with all undercuts, after 
which it is shellacked, dusted with soapstone and demounted from 
the articulator. A counter-impression is next made from it in 
oiled sand and the die formed by fillirm' this sand mould with 




Fig. .301. — Cast aluminum splint cemented to the teeth for the fixation of a 
fracture of tlie lower jaw at the . symphysis. In making this splint the patient's "bite" 
was taken in wax and the splint made from this so that the upper surface occludes 
with the upper teeth. Lack of occlusion between the splint and the upper teeth is 
uncomfortable and annoying to the patient during the after-treatment. 

molten zinc. After cooling the die is removed, inverted in the 
moulding flask and packed about with sand so that the tips of the 
teeth alone are exposed. Molten lead is then poured into the flask 
to form the first or shallowest counterdie. Three or four counter- 



FRACTURES OF LOWER JAW 365 

dies of graded depths should be made. This is accomplished by 
lowering the level of the sand in the flask, thus exposing a greater 
portion of the die to the molten lead. The splint is made by 
swedging metal between the die and counterdie. The most shallow 
counterdie is used first to start the metal of the splint, after which 
the deeper counterdies are used in order until by means of the 
deepest or complete counterdie the metal of the splint is forced 
into perfect form. Aluminum, silver or gold may be used in 
making the splint. After swedging is completed the splint is 
trimmed so that the edges will not imj)irige on tlie gums or cut 
the tongue. The final step consists in polishing, after which the 
splint is ready for use. The hollow side of tlie splint is then filled 
with cement and forced onto the teeth, care being taken to pre- 
vent the cement from being driven downward between the gums 
and teeth. The fixation of the splint to tlie teeth is rendered more 
secure by the use of Edmund's forceps (see Fig. 500) before the 
cement sets. This instrument is used to clamp the splint about 
the bases of the teeth, the set screw preventing the sharp jaws 
from slipping down onto the gums. 

This splint fits the crowns of the lower dental arcade and is 
attached to them by means of oxophosphatic cement which requires 
about one-half hour to become firmly set. During this time dis- 
placement is to be guarded against by firmly holding or binding 
the low^r jaw to the upper. This method requires considerable 
laborator}^ technique but when the patient has a good set of teeth 
to fasten the splint to, the method is probably the most perfect 
known. It is neat, efficient and allows easy cleansing of the mouth 
together with free motion of the jaw during the after-treatment. 
There are no bandages about the head and no clamps beneath the 
chin so that the patient is able to go about in public without being 
an object of curiosity. If wounds of the face accompany the 
fracture they may be treated without disturbing the fixation of 
the fragments. 

5. Wiring the lower jaw to the upper. — This is a method which 
has the disadvantage of not allowing motion of the mandible dur- 
ing treatment and renders feeding and cleansing of the mouth 
more difficult. On the other hand it secures good occlusion and 
does not require any special, complicated apparatus or laboratory 
technique for its employment. The question of apparatus or the 
assistance of a dentist is not a hindrance in large cities but when 



366 FRACTURES AND DISLOCATIONS 

the surgeon is called upon to treat the condition without these 
aids he will find that wiring together of the jaws, if properly car- 
ried out and due care exercised in the subsequent cleansing of the 
mouth, will meet the requirements in most cases and is productive 
of the very best results. 

The danger of vomiting during the time the jaws are wdred 
together should be constantly borne in mind, and the patient must 
be provided with wire cutting pliers so that the jaws may be 
promptly released at any time. For the same reason an anes- 
thetic must not be used in reducing the fracture if this method 
of immobilizing the fragments is employed. 

The details in tlie technique, of wiring the lower to the upper 
jaw, vary with different surgeons ])ut the essentials are tlie same. 




Fig. 502. — Oliver's metliod of wiring the lower to the upper jaw. A. shows the 
loop about the upper centrals. B. shows the manner in which the loops are attached 
to the molars. 

Whatever method is employed we may expect the wire to stretch 
during the after-treatment and the torsion strength of the wire used 
must be sufficient to stand the additional twisting without breaking. 
The method described by OJiver is probably as satisfactory as any 
and has the advantage of preventing, e^jually well, both lateral and 
perpendicular motion. The method is as follows; — ^"for purpose 
of illustrating the method let us sui)pose a case with simple frac- 
ture slightly transverse through socket (distally) of right first 
bicuspid and mental foramen, slight deformity, articular plane 
deranged, long anterior fragment drooi>ing somewhat and short 
posterior fragment drawn slightly upward and inward — the typi- 
cal picture. The mouth is first thoroughly cleansed with hot anti- 
septic wash and swabs, the location and extent of fracture 
determined and the fragments adjusted and articular plane re- 



FRACTURES OF LOWER JAW 367 

stored. Then a piece of soft drawn co]:)per wire, about four inches 
long-, previously annealed and sharpened at each end, is inserted' 
from without inward between the right lateral and cuspid, is 
pulled through about half its length, burnished lingually to cuspid 
and then inserted from within outw-ard between cuspid and first 
bicuspid, pulled through buccallv again, where it is held. The 
other end is now brought back and inserted at the latter inter- 
proximal space, pulled through taut, burnished lingually to first 
and second bicuspid, carried back across line of fracture, inserted 
from wdthin outward between first molar and second bicuspid, 
pulled through buccally again, brought forward taut across line 
of fracture and twisted with remaining ends at a point opposite 
an interproximal space. The adjustment of contour and articular 
plane is now verified : after wdiich the ends tightly twisted, bring- 
ing firm traction through axis of each fragment across line of 
fracture which temporarily will hold the parts in their exact posi- 
tion. The twisted ends are clipped off, leaving a stub about an 
eighth of an inch long ; this stub is turned upward and inward, 
entering the interproximal space far enough to prevent it from 
injuring any soft tissues with w^hich it may come in contact. Im- 
mobilization is next accomplished by w-iring lower to upper teeth, 
wdiile occupying normal occlusion. This is done by the following 
original method, wdiich insures against the possibility of any mo- 
bility, either lateral or perpendicular; first an anchor loop is made 
by taking a six-inch piece of annealed soft drawn copper wdre, 20 
gauge (B. & S.), bending it in the middle around a small-sized 
mandrel about one thirty-second of an inch in diameter, and twist- 
ing tight by one full turn with flat-nosed pliers (the twist may 
be strengthened by '^tacking" together with a small bit of hard 
solder). The two long ends are now straightened out and placed 
parallel to one another, one end being snipped ofi^ one-fourth of 
an inch shorter and both ends pointed. They are now inserted 
from without inward, bet^veen the two superior central incisors, 
pulled through taut until loop rests, horizontally, firm against both 
teeth at the mesocervical border. Each end is now carried lat- 
erally from median line, burnished, respectively, to lingual sur- 
face of each central, and inserted from within outw^ard between 
its respective central and lateral, pulled through firmly, brought 
forward to median line, above loop, and twisted tightly together. 



368 FRACTURES AND DISLOCATIONS 

clipping: off and turning stub into interproximal space as before 
noted. This forms a solid, permanently fixed, median anchor loop 
from which counter-traction may be had from each lateral half of 
the mandible for support and prevention of lateral mobility. 
Four pieces of the same wire, about three inches long, are in turn 
bent around the mandrel as before cited, forming the loop about 
one-third distant from one end and the long end sharpened. These 
lateral anchor loops are placed around solid teeth, one on each 
side, usualh^ first molars or second bicuspids, in both upper and 
lower jaws, and serve as anchorages for the traction wires, one 
for each side. These traction wires threaded through all the 
loops commencing with the median, then the superior lateral, then 
inferior lateral and finally twisted with outer end midway between 
inferior lateral and median loop, exert a firm and constant pres- 
sure between upper and lower jaws and at the same time maintain 
counter-traction laterally. The twist is clipped short and maj^ be 
turned upward under upper teeth. The lateral loops are posi- 
tioned by inserting long ends into mesoproximal spaces of the 
respective teeth selected, pulled through taut until loop rests hori- 
zontally against cervicoproximal border, then carried backward, 
burnished to lingual surface, inserted from within outward at 
distoproximal space, pulled through firmly and twisted to outer 
end as near the latter proximal space as possible in order that the 
increased size of twist, being too large to pull back through space, 
will prevent the anchorage loop turning under stress of subsequent 
traction and also that the twist may be clipped off and turned 
into the space as above shown. The traction wires are about seven 
inches long, of same material, and should be annealed before being 
used. Care should be exercised to keep each one perfectly straight 
between loops and pulled taut in passing through each loop. 
AYhen properly placed there will be a triangular geometrical figure 
with its first '^stretch" a long horizontal line from median to 
superior lateral loop, a short perpendicular line from the supe- 
rior to the inferior lateral loop and a long slanting diagonal line 
from inferior lateral to median loop, in which the twist has been 
made. AA'ith these heavy traction wires firmly fastened from each 
side of the jaw with teeth in normal contact, there is little likeli- 
hood of any kind of motion between either the fragments or the 
jaws. Should a wire break or become ineffective from being 
stretched, a very firm occipito-mental bandage is applied and both 



FRACTURES OF LOWER JAW 369 

traction wires cut aud removed. The anchorage loops are now 
tightened and new traction wires applied as before."^ 

The technique of simple wiring of the jaws together is less 
complicated than Oliver's method, but lacks some of its advan- 
tages. It is accomplished by passing loops about the teeth as 




Fig. 503. Fig. 504. 

Fig. 503. — Loops of wire passed about teeth of lower jaw preparatory to wiring the 
jaws together. 

Fig. 504. — Loops of wire passed about the upper teeth corresponding to those shown 
in Fig. 502. 




Fig. 505. Fig. 506. 

Fig. 505. — Two points of fixation in wiring the maxillae together. 
Fig. 506. — Opposite side in same case showing line of fracture and two additional 
points of fixation. 

shown in Fig. 503. The ends are twisted together to obtain a 
firm hold on the tooth and fastened with a similar pair of twisted 
ends which are secured to a tooth in the opposite arcade. With 
this method it may be necessary to replace the loops about the 
teeth if the wires break by twisting, or if it becomes necessarj^ to 
cut the wires in case of vomiting. Moreover the fixation is not 



1 R. T. Oliver, D.D.S., Jour. Amer. Med. Assii., Apr. 9, 1910. 



370 



FRACTURES AND DISLOCATIONS 



quite as secure as Oliver's method and it is not possible to release 
the jaws as quickly in case of emergency. 

Angle's hands and wire. — In place of the anchor loops described 
in Oliver 's method we may employ Angle 's bands such as shown in 
Fig. 510, They are ordinarily used in orthodontia but serve the 
purpose in fractures very nicely. They may be obtained at dental 
supply houses and the knobs for securing the traction wire may be 
attached to the band at any point desired by means of solder. 




Fig. 507. — Simple method of wiring the upper to the lower teeth in fracture of 
the lower jaw. This is the same method as demonstrated in Figs. 503, 504, 505 and 
506. Fragments held in good apposition in spite of dental deficiencies. 

Loops instead of knobs are sometimes used on the bands and are 
very satisfactory. Threaded bars and jack-screws are made to 
pass from an Angle band on one of the lower teeth to be anchored 
on a band placed on one of the teeth in the opposite arcade, but 
these should never be used since the jaws cannot be released 
quickly with wire cutting forceps in case of emergency. The 
Angle splint will be considered under the next heading. 

6. Seciinng the fragments by means of wiring the teeth of the 
lower jaw. — Various modifications of this principle have been 



FRACTURES OF LOWER JAW 371 

devised and in many instances the method is thoroughly satis- 
factory. An extremely old and sometimes efficient method is that 
of wiring the adjoining teeth. A loop of heavy wire is passed 
about four teeth (two on either side of the fracture) and the ends 
twisted tightly together, cut off and bent inward between the 
teeth so as not to injure the mucous membrane. It is usually 
difficult to set this wire sufficientlv tight bv twisting and when 




Fig. 508. Fig. 509. 

Fig. 508. — Angle's bands and bars applied to fracture of the mandible at the 
symphysis. 

Fig. 509. — Angle's bands and bars applied to fracture of the mandible between 
the second bicuspid and first molar. 




Fig. 510. — Angle's bands with knobs for wiring jaws together. 

Fig. 511. — Same case as shown in Fig. 510 showing opposite side of jaw with 
points of fixation on either side of fracture. 

such is the case a racking wire is passed between the teeth so as 
to include both arms of the loop. The ends of this wire are 
twisted tightly together and in so doing the internal arm of 
the loop is snugged up against the lingual surface of the 
teeth. The wire must include at least two teeth on each side 
of the fracture; if only one tooth on each side is included they 
will almost surely loosen, the object of fixation thus being de- 



372 FRACTURES AND DISLOCATIONS 

feated. A more secure method of wiring the teeth together is 
described by Oliver in the first part of his procedure (page 367). 
Any form of wiring must be closely watched and tightened to 
compensate for the loosening which is sure to take place. For 
this reason silver wire is not as satisfactory as some other forms 
on account of the likelihood of its breaking when much twisting 
is required. Bronze-aluminum wire of large caliber or ordinary 
electric wire, with the insulation removed, may be used. In any 
event the wire should be heavy and the ends pointed to facilitate 
its passage between the teeth. If it is desired to pass wire between 
the teeth where there is not sufficient space an opening may be 
made slightly below the gums by puncturing with a sharp instru- 
ment; this however is very rarely necessary. Wiring will have to 
be varied according to the nature and disposition of the teeth. 
When there is much tendency toward lateral displacement this 
method should not be employed; it is particularly inefficient when 
the line of fracture through the body is oblique, so that one frag- 
ment tends to slip past the other. 

Hammond's wire splint, a method which has been followed by 
good results, consists of a heavy iron wire encircling all the teeth. 
One continuous wire follows the lingual and buccal surfaces of the 
lower dental arcade. This wire should be heavy enough to with- 
stand the lateral strain and after fitting it to the teeth it is better 
to remove it and solder the ends together rather than to depend 
on simple twisting. With the wire in place about the lower 
denture a number of copper racking wires of lighter material are 
passed between the lingual and buccal arms of the splint and the 
ends twisted to secure the appliance in place. Edmund's forceps 
(Fig. 500) may be used to force the heavy wire of the splint more 
snugly against the cervical portions of the teeth and to facilitate 
tightening the racking wires. This method is usually not secure 
enough to allow motion of the jaw during the after-treatment but 
should be used in conjunction with some method of fixing the jaws 
together. 

Angle's splint consists of "bands fastened about the teeth with 
a threaded bar passing between them. The bands are similar 
to those used in wiring the jaws together but have heavy tubes 
soldered to them instead of the knobs. The tubes are placed 
horizontally on the buccal side and have a heavy threaded bar 
passing through them from one side of the fracture to the other. 



FRACTURES OF LOWER JAW 373 

When the uuts are placed and tightened the fragments are pulled 
together and held in firm apposition. The splint may be tightened 
by passing wire from band to band on the lingual aspect. 

Fracture of the ramus is a rare condition and is not, as a rule, 
accompanied by much displacement. Some form of fixing the jaws 
together will afford the necessary rest for the ramus and will be 
followed by good results in most cases. When much deformity 
exists open incision may be indicated to effect reduction. Wiring 
of the fragments may be called for if there is tendency toward 
displacement when the jaws are fixed. Fracture of the neck of 
the condyle, like fracture of the ramus, requires fixation of the 
jaws, and may require operative intervention if the displacement is 
pronounced. In operating in this region care must be exercised 
to avoid injury to Stenson's duct and the facial nerve (see Anat- 
omy, page 350). Fracture of the coronoid is extremely rare and 
will probably require only fixation of the jaws for a short time. 

Operative Treatment. — In some cases it may seem advisable in 
meeting the requirements of the case in hand to unite the frag- 
ments of the body of the bone by direct wiring or by the use of a 
small Lane plate. This is done through an incision parallel to 
and slightly below the lower border of the jaw. In making this 
incision care should be taken to avoid the facial artery which 
crosses the external surface of the bone in an upward and forward 
direction at the antero-inferior angle of the masseter. The bone 
having been exposed, holes are drilled in the positions of greatest 
advantage and wire passed, twisted, cut off and turned in. In 
oblique fractures with overriding tendency it is often best to have 
both arms of the loop passing through the plane of fracture in the 
substance of the bone. In transverse fractures a single loop with 
one arm on the external and the other on the internal surface of 
the bone will be sufficient to secure immobilization if the serrated 
edges of the fragments are well engaged and the wire properly 
tightened. 

It is well in any operative procedure about the jaw to refrain 
from removing loosened teeth and spicules of bone unless entirely 
separated from the surrounding tissues, since they usually become 
solid as a result of the free circulation in this region. In some 
cases of fracture of the jaw we have actual destruction of a con- 
siderable portion of the bone, and in other cases we have loss of 
osseous tissue through infection and necrosis and in such instances 



374 FRACTURES AND DISLOCATIONS 

it is difficult to obtain an end result which is perfectly satisfactory. 
When a portion of the bone is lost good occlusion is not possible 
and more or less deformity is bound to ensue unless some method 
other than those previously described is resorted to. In these 
cases much good can be accomplished by means of bone trans- 
plantation, although the method has not been sufficiently employed 
at the present time to state definitely what its limitations may be. 
However transplantation is justified and indicated, in view of the 
unhappy results following destruction of a portion of the jaw. 

The bone transplant is usually taken from some other portion 
of the patient's skeleton and placed in the mandible according 
to the principles of bone transplantation laid down in Chapter 
LX. 

The usual rules governing union in fractures do not hold good 
about the face since the free circulation is capable of withstanding 
greater insult and accomplishes great, rapid and extensive repair. 
Cases have been reported in recent years showing excellent results 
following transplantation of bone and what is still more surpris- 
ing the formation of new bone about metallic framew^ork previously 
built to fit the reciuirements of the case. This metallic frame- 
work has even been successful in the forming of a new condyle. 
The transplant is most easily and satisfactorily obtained from 
the crest of the tibia; it should be cut to accurately fit the defi- 
ciency in the jaw\ Its ends must be placed in firm apposition with 
the freshened, living ends of the maxillary fragments and should 
be immobilized by wire loops or plates. The transplant must not 
be exposed within the mouth but should be protected at least by 
mucous membrane. Transplantation should not be performed in 
the presence of infection ; it is essential to wait until all dead bone 
has sloughed out or been removed and the sinuses healed in, before 
the transplant or any other foreign material is introduced. In 
closing the incision after operation on the jaw a subcutaneous 
suture should be run, gathering in considerable tissue between the 
bone and the skin ; by this means we will avoid the unsightly re- 
tracted scars so frequently seen following operations on the jaw. 

The skin is best closed with horse-hair. If suppuration follows 
the operation we must see to it that drainage is free and complete 
but we should not be too hasty in removing foreign materials, 
since discharging sinuses in this region frequently close of them- 



FRACTURES OF LOWER JAW 375 

selves ill spite of the presence of foreign bodies such as suture 
materials, plates, etc. 

After-Treatment. — The after-treatment of fracture of the jaw 
consists ill keeping the mouth clean by means of mild antiseptic 
washes and seeing to it that the mechanical appliance in use is 
properly accomplishing its purpose of immobilizing the fragments. 
When a method is employed which keeps the jaws closed the pa- 
tient must be fed with liquids ; an aid to the introduction of food 
will be found in passing a tube between the cheek and the teeth, 
the end passing- behind the last molar. Eggs and milk will form 
the main part of the diet. These may be combined in different 
ways and various flavoring materials used to prevent the patient 
tiring of them. Soups and broths will add variety. 

It will usually not be necessary to keep the jaws together for a 
period longer than ten days or two weeks so that the inconvenience 
of feeding is not a long one. Union is well under way by this 
time but the mandible will not be in condition to stand any con- 
siderable strain until two months or more have elapsed from the 
time of fracture ; the patient should be cautioned in this regard. 

Prognosis. — The usual case of fracture of the body of the jaw 
should be followed by perfect function and no deformity. Cases 
in which the trauma has been severe and in which there have 
been multiple fractures are much more difficult to treat and ac- 
cordingh^ are sometimes followed by more or less loss of function 
and deformity. Protracted cases and those in which infection has 
occurred may be followed by damage to the articulation and in 
some instances ankylosis. The more complications the case pre- 
sents the worse the prognosis. 



CHAPTER XXIX. 

DISLOCATIONS OF THE JAW. 

Surgical Anatomy. — The temporo-maxillary articulation pos- 
sesses many anatomical features wliicli should be understood be- 
fore entering' upon the clinical aspects of dislocations of this joint. 
It is a gingiymo-arthrodial joint. The inter articular fibro-car- 
tilage, horizontally placed, divides the cavity within the capsule 
into two distinct articulations, each with its separate and complete 
synovial membrane. The function of the upper articulation is 
that of gliding, which is brought into action in the lateral grind- 
ing motions of the jaw, and when the chin is protruded. The 
lower articulation, between the cartilage and the condyle, has a 
purely hinge-like action, used in raising and lowering the man- 
dible. The peculiar formations of the condyle and glenoid cavity 
are difficult to appreciate unless one examines these surfaces on 
the skull, preferably in a fresh specimen. The nature of the 
articulation permits only of forward dislocation unless fracture 
complicates the condition. Backward, outward and upward dis- 
placements have been described though they are extremely rare 
Backward dislocation may occur when fracture of the neck of the 
condyle exists, and upward displacements have been reported as 
the result of the condyle having been driven through the glenoid 
cavity. 

The joint has practically three ligaments, the capsular, internal 
lateral and stylo-maxillary. The external lateral ligament is 
simply a thickening in the outer portion of the capsule, while the 
interarticular fibro-cartilage lies within the capsule and is -con- 
tinuous with it. The internal lateral ligament is entir'ely in- 
dependent of the capsule, being attached above to the spine of the 
sphenoid and below to the lingula. The stylo-maxillary ligament 
extends from the tip of the styloid process to the angle of the 
jaw. The anterior portion of the capsule is the only ligament 
limiting anterior displacement of the condyle after it has ridden 
over the eminentia articularis. 

376 



DISLOCATIONS OF JAW 377 

Dislocation of the jaw is almost always the result of muscular 
action, although violence has been known to have produced the 
condition. A blow on the chin, or a forward blow on the angle of 
the jaw while the mouth is open is known to have caused the 
luxation. It has occurred in yawning, talking, singing, coughing 
and vomiting. Overaction of the external pterygoid while the jaw 
is depressed is responsible for the luxation. When the condyle 
has been displaced far enough forward to become engaged in 
front of the prominence of the eminentia articularis, it is held in 
displacement by spasm of the internal pterygoid, masseter and the 
posterior fibres of the temporal. 

Etiology. — This dislocation occurs more commonly in middle 
aged persons and is more frequently seen in women than in men. 
It is usually the result of muscular action and rarely caused by 
violence. 

Symptoms. — In the usual bilateral dislocation the mouth is 
opened widely, and the entire jaw displaced forward. Saliva 
drools from the mouth. Articulation is impossible, and when the 
patient attempts to talk he is almost unintelligible. Considerable 
pain is experienced during the time the condylar processes are 
displaced. In the unilateral dislocation the mouth is open, chin 
protruded and displaced to the opposite side, which gives the face 
a peculiar twisted appearance. The displaced condyle may be 
felt below the zygomatic arch and a depression exists just in front 
of the ear indicating the empty glenoid cavity. 

Treatment. — Reduction is accomplished by forcing the rami of 
the jaw downward and backward as the body of the bone is raised. 
The thumbs are protected by a towel, or heavy bandages, intro- 
duced into the mouth and carried as far back as the last molars 
on either side, the opposing fingers then secure the lower border 
of the body of the bone. Downward and backward pressure is 
then made by the thumbs, forcing the condyles over the articular 
eminences as the body of the bone is raised. The thumbs should 
be removed before the molars come together. The spasm of the 
muscles previously referred to sometimes offers a most serious ob- 
struction to reduction even to the extent of necessitating an anes- 
thetic. It is surprising with what facility reduction may be ac- 
complished with the muscles relaxed in cases in which the jaw 
seemed immovable in its displacement before an anesthetic was 
given. It is extremely rare to find a case in which reduction can- 



378 FRACTURES AND DISLOCATIONS 

not be accomplished under anesthesia. If the displacement has 
existed for some months the formation of adhesions about the 
condyle and changes in the glenoid cavity may necessitate open 
incision to effect reduction. If necessary the condyle may be 
resected with a view to the formation of a new joint. 

After-Treatment. — The jaw should be fixed for a period of two 
weeks following the accident. This is readily accomplished by 
means of a four-tailed or Barton bandage. The patient should 
be cautioned not to open the mouth too far for at least another 
month following the removal of dressings. When dislocation of 
the jaw has once taken place it is likely to occur again, and unless 
the patient is apprised of this fact he may feel that the treat- 
ment was not successful if luxation recurs even at a remote 
period. 

Prognosis. — Eeduction is usually accomplished without difficulty 
in recent eases. Restoration of function is perfect with the ex- 
ception of a tendency to habitual luxation which exists in all 
cases. 



CHAPTER XXX. 

SCALP AA^OUNDS. 

AYoiinding of the scalp is sueli a frequent and important compli- 
cation of fracture of the skull, that the management of these 
wounds is best considered before entering upon the subject of 
injury to the skull and brain. Fracture of the vault of the skull 
is usually accompanied by wounding of the scalp or, in other 
words, the fracture is compound; and the successful treatment of 
the wound will often determine whether or not infection will 
follow the injury, and hence is of the greatest importance. 

Surgical Anatomy of the Scalp. — The scalp is composed of five 
layers : 

1. The skin. 

2. The subcutaneous layer of fat. 

3. The occipito-frontalis muscle and its aponeurosis. 

4. The subaponeurotic connective tissue. 

5. The pericranium. 

These layers individually and collectively are of considerable 
surgical importance and should be understood when treating 
wounds of this region. The skin of the scalp, the toughest and 
thickest in the entire body, is supplied with numerous hair fol- 
licles and sebaceous glands. The subcutaneous layer of fat has 
bundles of fibrous tissue passing through it in all directions, and, 
together with the skin, is firmly adherent to the aponeurosis of 
the occipito-frontalis which lies directly below it. The hair fol- 
licles of the skin extend down into the subcutaneous tissue, and in 
gaping wounds the bulbous ends of the follicles may be seen by 
everting the edges. The aponeurotic layer or galea is composed 
anteriorly, of the frontalis muscle, which is inserted into the skin, 
posteriorly, of the occipitalis muscle, which arises from the superior 
curved line of the occipital bone, and the aponeurotic tissue or 
tendon which extends between these two muscles and divides the 
scalp surgically into two layers; — the superficial and deep. 

379 



380 FRACTURES AND DISLOCATIONS 

Wounds which divide the aponeurotic layer Avill gape, while 
wounds which penetrate only to the galea will present approxi- 
mated edges. Transverse wounds dividing the galea usually gape 
more widely than wounds of the same depth running in an antero- 
posterior direction. The three superficial layers just named are 
loosely connected with the deeper structures by means of an areo- 
lar tissue which allows free motion of the upper layers over the 
skull. The layer of subaponeurotic connectiA^e tissue is of the 
greatest surgical importance since infections in this loose areolar 
tissue, following the lines of least resistance, may spread, and if 
not promptly and freely drained the entire calvarium may be 
covered by the infection and the scalp ^'floated" with pus. The 
pericranium is the deepest layer, covers the calvarium and acts 
as a modified periosteum. It differs from periosteum in other 
regions in the following respects : the pericranium does not re-form 
bone following loss of osseus tissue to the extent observed in peri- 
osteum elsewhere; the circulation is less free; and it may b,e 
stripped from the bone without causing any serious disturbance in 
the nutrition of the denuded osseous tissue. Where the pericran- 
ium crosses the sutures it is intimately connected with the inter- 
sutural connective tissue, though in other portions of flie skull 
it may be readily stripped from the bone. The scalp as a whole, 
together with the hair, affords an excellent protection to the skull 
and is richly supplied Avith blood vessels. The main portion of the 
circulation of the scalp runs in the subcutaneous connectiA^e tis- 
sue and in the skin itself, and its richness accounts for the re- 
markable reparatiA^e properties of the scalp, which are not equalled 
elscAvhere in the skin of the body except the face. The amount of 
fibrous tissue present in the layer in Avhich the blood vessels run 
accounts for the profuse and prolonged hemorrhage so common in 
scalp wounds. This fibrous tissue prcA^ents the vessels from clos- 
ing as they do elsewhere folloAving injury, and explains the diffi- 
culty so frequently experienced in catching and ligating A^essels 
in the scalp. The mobility of the scalp Avill often save the parts 
from wounding by alloAving them to give before the vulnerant 
body. 

Vessels of the Scalp. — In the frontal region Ave have the frontal 
branch of the ophthalmic artery AA-hich emerges from the inner 
angle of the orbit and anastomoses with its fellow of the opposite 
side and Avith the supraorbital artery. The supraorbital artery is 



SCALP WOUNDS 381 

a branch of the ophthalmic, of larger size than the frontal. It 
emerges from the orbit through the supraorbital notch at the 
junction of the inner and middle thirds of the supraorbital ridge, 
and divides into superficial and deep branches anastomosing with 
the frontal and anterior branch of the superficial temporal artery. 
The side of the scalp is supplied by the superficial temporal, a 
branch of the external carotid artery, which may be palpated as 
it ascends just in front of the auricle. This artery divides into 
an anterior and posterior branch and anastomoses with the deep 
temporal arteries; the anterior branch of the superficial temporal 
anastomoses with the supraorbital, and the posterior branch 
anastomoses with the posterior auricular and occipital arteries. 
The deep temporal arteries are two branches of the internal maxil- 
lary; they supply the temporal fossa, anastomose with each other 
and with the superficial temporal and lachrymal arteries. The 
occipital and posterior auricular arteries, — branches of the ex- 
ternal carotid, — supply the posterior portion of the scalp as far 
forward as the ears, and anastomose with each other and the 
posterior branch of the superficial temporal artery. The occipital 
artery passes onto the scalp at a point about midway between the 
inion and the external auditory meatus and in this region is more 
or less exposed to injury ; when opened it may give rise to profuse 
hemorrhage. It may be temporarily controlled by compressing 
it against the skull on the proximal side of the wound. All of 
the arteries of the scalp may be temporarily controlled by the 
application of an elastic tourniquet about the head, which is kept 
in place until the main branches are secured with ligature. The 
arteries most likely to cause free hemorrhage are the occipital and 
superficial temporal, either of which may be controlled by digital 
pressure against the skull below the wound. The anastomosis be- 
tween the above named arteries is very free, and the size of the 
vessels is large for the region supplied; the result is that the 
blood supply to the scalp is great, and the vitality of the tissues 
correspondingly high. 

The veins of the scalp correspond to the arteries just named, 
though there are some differences which are worthy of surgical 
note. The supraorbital vein anastomoses with the cavernous sinus 
by means of the angular vein near the inner angle of the eye, and 
thus infection in the region of the forehead may be drained into 
the cavernous sinus as well as into the facial vein, which is the 



382 FRACTURES AND DISLOCATIONS 

continuation of the supraorbital, corresponding: to the arterial 
arrangement in this region. The superior longitudinal sinus re- 
ceives blood from outside the skull by means of the vein which 
passes through the parietal foramen, and in like manner connection 
is established between the scalp and lateral sinuses through the 
mastoid and posterior condyloid veins. These anastomoses are of 
importance in showing the Avay in which infection may pass from 
the outer surface of the skull to the intracranial sinuses. 

The lymphatic vessels form a free anastomosis in the scalp from 
which are derived the main trunks which follow the course of the 
arteries. The anterior portion of the scalp is drained into the 
submaxillary glands; the temporal region and that portion of the 
scalp above it is drained into the superficial and deep parotid lym- 
phatic glands. That portion of the scalp lying behind a vertical 
line connecting the two external auditory meati is drained into the 
occipital and posterior auricular glands. 

The nerves of the scalp may be divided into sensory and motor. 
The sensors^ nerves are of cranial and cervical origin. The an- 
terior portion of the scalp is supplied by branches of the fifth 
cranial nerve and extends upward to about the middle of the 
vertex. The posterior portion of the scalp is supplied hy branches 
of the upper cervical nerves. The sensory nerves may cause con- 
siderable pain lasting over a long period of time if the}^ become 
caught in scar tissue and may necessitate operation to afford the 
patient relief. 

All the muscles of the scalp are supplied by the facial nerve ; 
the occipitalis muscle sometimes receives additional filaments from 
the occipitalis minor nerve. The upper branch of the "pes an- 
serinis, " supplying the frontalis, is the most frequently injured 
motor nerve in the scalp. Inability of the patient to wrinkle the 
corresponding half of the forehead should lead to a search for the 
divided ends of this nerve before a scalp wound of this region is 
closed. 

Pathology and Symptoms. — "Wounds of the scalp may be classi- 
fied as incised, punctured; lacerated and contused; the nature of 
the wound depending on the character of the vulnerant body and 
the degree of trauma causing the injury. In addition we may have 
a simple contusion without an opening or wound in the scalp, and 
although it cannot properly be considered as a scalp wound yet 
its importance requires consideration under this heading. Simple 



SCALP WOUNDS 



383 



contusion of the scalp is common and may lead to collections of 
blood or serum in any of the various layers of the scalp. When 
the collection of blood is in the movable layer of the scalp (i. e., 
above the galea) it will be found to be freely movable with the 
skin and quite circumscribed. When the fluid is below the galea 
it is not movable, is much more diffused and may present a cir- 
cumference of induration which, when palpated in connection with 
the softened centre of the effusion, gives one the sensation of a 
depressed fracture. Continued digital pressure on this margin 
of induration will usually cause the fluids to be displaced suffi- 
ciently to differentiate, but if this is not satisfactory a needle may 
be used or the parts incised. 

Effusions below the epicranium are rare except in infancy ; when 
they do occur they will be found limited to one cranial bone of 
the vault, since the fusion of the epicranium with the intersutural 
fibrous tissue stays the further spread of the blood. Birtli trauma 
and the free vascular connection between the epicranium and the 
skull in infancy accounts for the comparative frequency of such 
effusions (cephalhematomata) during that period. 

The incised' wound, strictly speaking, is caused by some object 
with a sharp or cutting edge, yet there is a distinction which must 
be made between a truly incised wound and an apparently incised 
wound which has been produced by some blunt instrument, such 
as a club. A scalp wound produced by a club may, to the inex- 
perienced, have all the characteristic appearances of an incision, 
though on closer inspection it will be found to have a slightly 
ragged and contused edge and the underlying structures will not 
be found divided as by a knife. The cause of wounds has an im- 
portant medico-legal significance, and when the attending surgeon 
is called upon to give testimony he should be aware of the close 
similarity existing between true incised wounds and those made by 
a dull instrument. The mechanism of the pseudo-incised wound 
has been likened to the splitting of a kid glove, struck with a cane 
while the leather is stretched across the knuckle. 

The punctured variety of wound in the scalp is produced by 
pointed instruments, and the fact that the depths of the wound are 
not easily inspected without exploratory incision accounts for the 
overlooking of injury to the underlying skull and brain in many 
instances. It should be remembered that the punctured wound 
has the traumatic energy distributed over a very small area and 



384 FRACTURES AND DISLOCATIONS 

is therefore more likely to do damage to the underljdng structures. 

Laceration of the scalp may exist in all degrees, from a slight 
tear to a complete avulsion. The average scalp wound shows some 
degree of laceration and more or less contusion, so that for prac- 
tical purposes wounds presenting these features are best considered 
under one heading. The tissues of the scalp may be torn and 
bruised in various ways, and the degree of injury ranges from the 
most serious to the most trivial; the important question in each 
case — so far as the scalp itself is concerned — is, what portion of 
the tissues injured has been damaged beyond recovery? This 
question can only be answered by a careful examination of the 
wound and an estimation of the circulation remaining in the 
ragged, mashed and torn edges. 

Dirt, cinders, gravel, broken glass and various other materials 
may be ground into the wound and the surrounding scalp, and if 
allowed to remain will act as foreign infectious bodies within the 
tissues. Loose hair is a very common material found within the 
wound and when not removed is almost sure to be followed by 
suppuration. 

A common form of lacerated, contused scalp wound is one in 
which the blow causing the wound has resulted in the traumatic 
death of more or less tissue, which will ultimately slough out if not 
removed at the time of operation. When the edge of the wound 
shows slight laceration union can often be expected even if the 
lacerated edges are not trimmed away, but when the laceration 
is severe and the edges mashed, we may look for more or less 
sloughing if this tissue is not removed, regardless of the presence 
or absence of infection. "When the devitalized tissue is extensive 
it may become impossible to remove it and approximate the edges. 
Inflammatory reaction is much more pronounced in contused 
wounds than in simple incision or puncture. A type of injury 
frequently seen is one in which one side of the wound has been 
slid and separated from the underlying structures as the result 
of a glancing blow, and the pocket thus formed under the scalp 
often contains infectious "m^aterials which have been forced into 
the wound at the time of injury. 

Complications and Sequelae. — The complications may be grouped 
under three headings: hemorrhage, infections and conditions ac- 
companying fracture of the skull and brain injury. Late compli- 
cations or sequelae are painful scar, aneurism of the scalp; deform- 



SCALP WOUNDS 385 

iug contractures of scar tissue, tumor formation in the scar (kel- 
oids and rarely malignancjO together with the late complications 
following brain injury. 

Treatment. — The treatment of these wounds will depend on the 
conditions present in each individual case and it will be impos- 
sible to formulate the routine to be followed in all instances. A 
scalp wound may be present without any evidence of injury to 
either skull or brain, the patient not having suffered the slightest 
concussion, while on the other hand the scalp wound may be a 
part of a serious condition in which the skull is fractured, the 
brain injured and the patient in extremis. These extremes to- 
gether with the intermediate conditions require the greatest acu- 
men and surgical judgment so that we may not subject the patient 
to unnecessary operation on the one hand, and also avoid the over- 
looking of serious complications on the other. There are, how- 
ever, some general principles which should be followed in the 
treatment of these wounds, though the relative importance of each 
will vary in different cases. They are as follows : 

1. Control hemorrhage. 

2. Prevent infection as far as possible. 

3. Avoid the overlooking of complications especially of skull 

and brain. 

4. Close the wound as far as may seem advisable, providing 

drainage when necessary. 

1. Control of hemorrhage. — The nature and amount of hemor- 
rhage will depend upon the character of the wound and the 
vascular structures divided ; it may be arterial or venous, and may 
consist of a simple oozing or an active spurting. The hemorrhage 
may be surprisingly profuse, when some of the main arteries of 
the scalp are divided, and when such is the case the first step in 
treatment must be the control of this bleeding. "When the artery 
is accessible it should be secured with hemostats for the time being, 
until the scalp has been appropriately cleaned; if the hemorrhage 
consists of moderate or slight oozing it may be neglected during the 
process of cleansing. In some cases it may become necessary to 
further open the scalp to expose the bleeding artery. In the most 
profuse hemorrhages we may secure temporary hemostasis by pack- 
ing a gauze sponge into the wound and making firm pressure on 
it with the hand. In the case of hemorrhaore from a sino'le laro-e 



386 FRACTURES AND DISLOCATIONS 

artery, such as the occipital or superficial temporal, we may com- 
press the vessel against the skull a short distance to the proximal 
side of the wound pending the proper securing and ligation of 
the bleeding end. In extreme cases an elastic bandage may be 
used to encircle the head so that it passes just above the brows 
and ears and in this manner all the large vessels of the scalp will 
be compressed against the skull. 

One of the most annoying forms of hemorrhage is that of a 
persistent oozing which continues even after the wound has been 
thoroughly prepared and is ready for the sutures. This oozing 
may come from the edge of the wound proper or it may come be- 
tween the layers of the scalp in cases where the injury has been 
produced by a glancing blow and one side of the wound has been 
separated from the underlying tissues by "sliding." Such oozing 
is not, as a rule, dangerous in itself but if allowed to continue after 
the wound has been closed, will result in the formation of clots 
which can only favor subsequent suppuration. The drier the 
wound Avhen closed (other things being equal) the more reason we 
have to anticipate prompt healing. Oozing may be checked in 
many ways ; by the use of heat, pressure, styptics and sutures, or a 
combination of these. A method which will in most instances be 
found all that is required, is as follows: take a gauze sponge of 
appropriate size wrung out of hot salt solution, pack it into the 
wound and make firm pressure with the hand from two to three 
minutes. When the sponge is removed the wound surfaces will 
be found dry and will not begin to bleed again unless roughly 
handled. This procedure is best carried out just before closing the 
wound Avhen the manipulations necessary to preparation have been 
completed. A solution of 1 :2,000 of adrenalin may be used to 
advantage in controlling oozing but strong chemical styptics should 
be avoided because of the injury they do to an already trauma- 
tized tissue. Oozing from the edge of the wound, especially of 
the venous type, will almost invariably stop when the sutures are 
placed and tied. After the wound has been closed it is advisable 
as an additional precautioli to make pressure from one to two min- 
utes to prevent the continuation of oozing and to express any 
blood which may have collected under the closed scalp. When it 
is necessary to leave buried sutures within the tissues plain cat- 
gut will be found the best. If hemorrhage can be controlled 
without the use of buried sutures it should be done. 



SCALP WOUNDS 



387 




Fig. 512. — Ordinary scalp wound iJivpart'd for sntnre. Note the clean shavino; of 
the scalp. 




Fig. 513. — Sutures taken to bring the mui-gins of the wound together, 




Fig. 514. — Recurrent bandage of the injured side of head with strips of adhesive 
applied to prevent slipping. 



388 FRACTURES AND DISLOCATIONS 

2. The prevention of infection is to be accomplished along lines 
similar to those already laid down under the ''Treatment of Com- 
pound Fractures" (see page 789). Too much cannot be said in 
condemnation of the so-called antiseptics, such as bichlorid of mer- 
cury, which invariably do more harm to the already damaged tis- 
sues than they do to the germs of infection. The wound should 
be treated by attempting to remove the infection which has already 
gained entrance and not by killing it in situ. In other words we 
should endeavor to render the wound aseptic rather than anti- 
septic. It is of course practically impossible to remove all infec- 
tion from the scalp, yet w^e may so reduce the number of bacteria 
present when the wound is thoroughly prepared that nature is 
enabled to dispose of those remaining without the formation of 
pus, in which case the wound is said to heal by first intention. 

Crushed and devitalized tissue has no resistance and can serve 
no purpose within the wound except to act as a culture medium 
for infection and the same may be said of collections of dead 
blood. The indications therefore are to approximate healthy tis- 
sue and to avoid the extravasation of blood and serum within the 
wound. Clinically every scalp wound must be considered infected, 
yet we must not lose sight of the fact that additional infection and 
germs of different strains may be introduced within the wound by 
the surgeon, if aseptic regulations are not observed. The first 
indication in the treatment of scalp wounds (aside from the con- 
trol of severe hemorrhage) is the shaving of the scalp surrounding 
the wound and the cleansing of the wound itself. Blood and dirt 
should be wiped away from the hair which is then clipped away 
for a distance of two to two and a half inches surrounding the 
wound. This region is next covered with lather and shaved, care 
being exercised to prevent the hair and dirt from entering the 
wound. After this has been accomplished the wound is irrigated 
with salt solution and the unshaved portions of the scalp dried 
with a sterile towel. 

When the surgical surroundings are favorable an assistant 
should perform the preparation just described so that the surgeon 
may approach the prepared scalp with clean hands. If, however, 
the surgeon is treating the wound unassisted he should re-sterilize 
his hands and whatever instruments may have come in contact with 
the wound during preparation in order that the subsequent ma- 
nipulations may be rendered sterile. The scalp is then once more 



SCALP WOUNDS 389 

irrigated in and about the wound and the surgeon is ready to 
explore the depths of the wound to remove infectious materials 
such as hair, felt, gravel, cinders, etc., and to trim away devitalized 
tissue. Isolated hairs show a strong tendency to cling to the inside 
of the wound and it is frequently necessary to pick them out in- 
dividually with thumb-forceps even after the wound has been 
thoroughly irrigated and is supposedlj^ clean. Tincture of iodine 
may be used on the surface of the scalp, either full strength or 
diluted, but is best kept out of fresh scalp wounds. Other anti- 
septics within the wound are not only useless but harmful and 
should not be employed. 

3. Detection of complications. — After the hemorrhage has been 
controlled and infection prevented, as far as possible, the wound 
is ready for the sutures, but before these are placed the surgeon 
should satisfy himself that no symptoms of complications have 
escaped observation. The majority of scalp wounds may be ex- 
plored sufficiently without incision to satisfy oneself as to the con- 
dition of the underlying skull, and when further opening of the 
scalp is necessary it is in most instances easily accomplished under 
local anesthesia. The local examination should be carried to a 
conclusion satisfactory to the surgeon and other symptoms of frac- 
ture of the skull noted when present. The ears and nose should 
be examined for hemorrhage and the eyes examined as to their 
position and pupillary reactions, the consciousness of the patient 
noted and the deep reflexes of the two sides compared. In other 
words, if fracture of the skull is present or suspected we should 
examine the patient for all the symptoms both local and general 
which are known to occur following; fracture of the skull. (See 
symptoms of "Fractures of the Skull," page 411.) 

4. Closure of the wound. — After the preceding three steps have 
been carried out the wound should be closed by interrupted 
sutures, preferably of silk worm gut, extending down to but not 
penetrating the galea. The question of drainage is a difficult one 
to settle and mistakes are sometimes made by those possessing the 
greatest experience. The greater the contusion or laceration the 
greater the probability that the wound will need drainage. If the 
patient can be kept under close observation following the closure 
of the wound it will usually be unnecessary to provide drainage, 
since pus can be detected and evacuated with little difficulty should 
it form within the wound. If, however, the circu.mstances are such 



390 FRACTURES AND DISLOCATIONS 

that the patient is not seen for a day or two following the first 
treatment, it is safer to provide drainage. When the drain is em- 
ployed it should be placed in the most dependent position possible 
and when necessary counter-openings are to be made through the 
scalp and drains inserted. A rubber tube about the size of a thin 
lead pencil, sewed into the lower angle of the wound will be found 
a satisfactory form of drain. The wound may then be covered 
with gauze and a recurrent bandage applied to the head. When 
the wound is small the gauze dressing may be secured to the shaven 
scalp by means of collodion. 

After-Treatment. — The most important element in the after- 
treatment consists of the detection of pus within the wound; the 
case should therefore be kept under close observation. The wound 
should be dressed and inspected at least once in twenty-four hours 
during the first week and if pus is suspected a fine probe, pre- 
viously sterilized, in a flame, may be passed into one corner of 
the wound and the content, if present, evacuated. If pus does 
develop during the after-treatment, it should be thoroughly evacu- 
ated and openings maintained sufficiently large to allow free egress 
of the septic detritus. An infected wound should be freely drained 
so that granulation tissue will fill it from the bottom. The aver- 
age clean wound will be solidly healed in ten days and the stitches 
should be removed on the eighth or ninth day. When the wound 
is infected the healing is much sloAver, sometimes lasting for weeks ; 
during the treatment of this type of wound granulations may 
be stimulated by the use of balsam of Peru, and in some cases 
tincture of iodine painted over a foul granulating surface will 
render it clean and active in the course of a few days. The way 
in which iodine acts is uncertain yet excellent results follow its use 
in selected cases. The application of iodine to granulation tissue 
is quite different from its use on a fresh wound, where no special 
resistance has been developed, the circulation of the parts is not 
intact, and the vitality of the tissues reduced by trauma. When 
the loss of tissue is such that the scalp cannot bo closed at the 
first treatment, skin-grafting should be resorted to if the defect 
is one which cannot be filled by granulation within the first two 
or three weeks. 



CHAPTER XXXI. 

FRACTURES OF THE SKULL. 

The skull is the bony protection of the brain and when this pro- 
tective wall is injured the brain is likely to suffer, at least in- 
directly. The brain may suffer injury from penetration of the 
vulnerant body, by pressure from depressed fragments, by ex- 
posure of its substance; by concussion, contusion, laceration, in- 
fection and degenerative sequelae such as cysts and abscesses. 

Fracture of the skull and injuries to the brain are distinctly 
different subjects, yet the frequency with which they are asso- 
ciated makes it necessary to consider them under one heading. If 
the bone lesion were all that we had to confront us in these cases 
the matter would be simple, but with the addition of injury to the 
brain it becomes one of the most complex conditions with which 
we have to deal. Any, all, or none of the symptoms to be enu- 
merated may be present in a given case at the time of examination ; 
accordingly fracture of the skull may be the easiest or the most 
difficult of conditions to diagnosticate. The proper treatment will 
usually depend on the proper diagnosis, and a proper diagnosis 
often calls for the most careful observation and consideration of 
every symptom present. 

Fracture of the skull may be divided into three groups : 

1. Those in which recovery would take place without treat- 

ment. 

2. Immediately fatal cases, and those who live but a few hours 

(all treatment being futile). 

3. Those whose lives can be saved or in whom serious sequelae 

may be averted by proper treatment. 

The last group is the one to which our attention is directed. It 
is however no simple matter to determine at the time of examina- 
tion to which group a given case may belong. The unexpected 
is more common in head injuries than in other fields of surgery; 
an apparently slight injury may result in death while a case 

391 



392 FRACTURES AXD DISLOCATIONS 

presenting grave symptoms may recover. There is no absolute 
means of avoiding mistakes in the diagnosis and treatment of these 
cases, yet careful observation combined with sound judgment, — 
the fruit of study and experience, — will reduce these mistakes to 
a minimum. 

Classification. — Fractures of the skull have been variously classi- 
fied and the terms used indicate the conditions without further 
definition. We have fracture of the vault, fracture of the base 
and fractures involving both vault and base. Fractures of the 
base may be classified according to the fossa involved. There are 
fissured fractures, depressed fractures, comminuted fractures, etc., 
the same terms being used as are applied to fractures in general. 

Surgical Anatomy. — A knowledge of the anatomy of the skull 
and brain is essential to the proper interpretation of symptoms and 
the administration of treatment, but the subject is so extensive that 
it will be possible to consider briefly only the most salient features ; 
the reader being referred to text-books on anatomy for more de- 
tailed accounts. 

Bones of the Skull. — Development. — The bones of the vault 
(tabular portion of the occipital, parietals, squamo-zygomatic por- 
tions of the temporals, and the frontal) are ossified in membrane 
from centers which appear at about the end of the second foetal 
month. Ossification beginning in the center of a cjuadrilateral 
bone reaches the corners last and accordingly at birth we find the 
"fontanelles" which represent the unossified portions of the bones 
of the vault. These fontanelles are situated at the four angles of 
the two parietal bones and are therefore six in number. The 
four lateral fontanelles at the lower angles of the parietal bones 
are closed a short time after birth ; the one situated at the junc- 
tion of the sagittal and lambdoid sutures closes within the first 
few months of life ; the one remaining, situated at the bregma, con- 
tinues open during the first year. Although the process of ossi- 
fication begins earlier in the vault of the skull than in the base, 
nevertheless, at birth, the base is far more completely ossified than 
the vault. The base is ossified in cartilage as is the rest of the 
skeleton. Wormian bones occur most frequently in the course 
of the lambdoid suture but are not uncommonly found in the 
fontanelles: the suture surrounding them may at first sight be 
mistaken for a linear fracture while exploring wounds of the scalp. 
In the aged the frontal, parietals and occipital are practically one 



FRACTURES OF THE SKULL 393 

coutimious bone due to the ossification of the sutures between them ; 
the basilar process is continuous with the body of the sphenoid 
and the lesser wings of the sphenoid are continuous with the orbital 
plates of the frontal. The lambdoid suture meets the sagittal suture 
at a point about two and a half inches above the inion. The cen- 
ter of the anterior fontanelle (the bregma) is at a point about 
one-fourth inch anterior to a vertical line connecting the external 
auditory meati. The intersutural fibrous tissue acts as a linear 
shock absorber which interrupts or reduces vibrations passing 
from one cranial bone to another. The bones of the skull are com- 
posed of two layers of compact tissue between which is interposed 
a layer of cancellous tissue known as the diploe or diploic layer. 
The outer layer is heavier, stronger and less brittle than the inner. 
The skull is by no means of a uniform thickness throughout, which 
fact may be nicely demonstrated by holding the base of the skull 
up against the light and noting the places which are translucent 
and those which are opaque. The thin regions are produced, to 
some extent, by obliteration of the diploe, and these areas of thin- 
ness and thickness are of importance in trephining and in estimat- 
ing the probability of penetration in a given region. The thin 
places in the skull are the orbital plates of the frontal (supporting 
the frontal lobes), the squamous portions of the temporals (in 
contact with the spheno-temporal lobes) and the middle of the 
posterior fossa below the grooves for the lateral sinuses (which 
accommodate the cerebellum). At any of these places a well 
directed blow with a pen-knife could penetrate the skull and in- 
jure the brain. In contrast with the regions of thinness there are 
ridges which act as buttresses and serve to strengthen the skull. 
In the vault, they are situated as follows: the torus transversus oc- 
cipitalis, a thickening in the bone extending laterally from the 
external occipital protuberance, a median thickening of the skull 
extending from the glabella to the foramen magnum and corre- 
sponding to the course of the superior longitudinal and occipital 
sinus, and the temporal crests ascending from the external angular 
processes of the frontal to be continued into the temporal ridges. 
In the base we have the ridges which divide the region into the 
three foss« and notwithstanding the fact that they are composed 
largely of thin, brittle compact tissue, they serve nevertheless to 
reenforce this part of the skull. They are : the petrous portion of 
the temporal and the lesser wing of the sphenoid. The base of 



394 FRACTURES AND DISLOCATIONS 

the petrous portion of the temporal is applied to the skull in a 
region which corresponds to the mastoid externally and accord- 
ingly this part is comparatively strong. The foramen magnum 
is also surrounded by a ridge which is a bifurcation of the internal 
occipital crest, the two divisions ascending anteriorly to the pos- 
terior clinoid processes. These thickenings in the skull all have 
more or less tendency to modify vibrations and hence, to stop or 
divert lines of fracture. 

The foramina in the base of the skull are said to weaken it, 
and are of importance since the study of their positions and con- 
tents will aid in determining the location of the fracture. In the 
anterior fossa we have the cribriform plate of" the ethmoid, the 
thinnest and weakest place in the floor of this fossa. It transmits 
the olfactory and nasal nerves, the latter passing through the nasal 
slit. In the middle fossa we have the sphenoidal fissure which 
transmits the nerves and vessels passing to the orbit : The motor 
occuli, abducens, patheticus, the three branches (nasal, lachrymal 
and frontal) of the ophthalmic and the sympathetic nerves as they 
pass from the walls of the cavernous sinus to the orbit. These 
nerves are accompanied by three vessels: The orbital branch of 
the middle meningeal artery, a recurrent branch of the lachrymal 
artery and the ophthalmic vein. The foramen rotundum and ovale 
in the same fossa transmit respectively the second and third 
branches of the fifth cranial nerve together with other structures 
of minor importance. The middle meningeal artery enters the 
skull through the foramen spinosum situated in the tip of the 
great wing of the sphenoid. Through the carotid canal we have 
the internal carotid artery entering the cranial cavity accompanied 
by the carotid plexus of the sympathetic, the latter being con- 
tinued into the cavernous plexus when it reaches the side of the 
body of the sphenoid. The foramina in the posterior fossa are the 
foramen lacerum posterius or jugular foramen, the internal audi- 
tory meatus, the two condyloid foramina and the foramen mag- 
num. The jugular foramen transmits the glosso-pharyngeal, pneu- 
mogastric, and spinal-accessory nerves; also the lateral and in- 
ferior petrosal sinuses and a small artery. The inferior petrosal 
and lateral sinuses join to form the internal jugular vein a short 
distance outside the skull. The anterior condyloid foramen trans- 
mits the twelfth cranial nerve and occasionally an artery, the 
posterior condyloid foramen transmits a vein which establishes 



FRACTURES OF THE SKULL 395 

commimication between the lateral sinus and the deep veins of the 
neck. The internal auditoiy meatus transmits the facial, the audi- 
tory and the pars intermedia of AVrisberg, also a branch from the 
basilar artery. The gustatory fibres of the seventh join the nerve 
as it enters the internal auditory canal and leave it by way of the 
chora tympani. 

]\Iembranes of the Brain. — The brain as it lies within the skull 
is enclosed within three membranes which conform more or less 
closely to its surface. 

The dura, the most superficial of the three, is composed of tough 
inelastic tissue which acts as the internal periosteum of the skull 
and is richly supplied with blood vessels. Most of the nutrition 
of the bones of the skull is derived from vessels running in this 
membrane. The dura is composed of two layers, a superficial and 
a deep. The superficial, or vascular, layer acts as the endosteum 
while the deep layer is lined with endothelium on its deep surface, 
and dips down between certain portions of the brain to form 
partitions and give support. The dura as a whole is more firmly 
adherent to the skull in childhood and in old age than it is in mid- 
dle life ; it is more firmly adherent at the base and where it crosses 
the sutures than elsewhere. Sir Chas. Bell has demonstrated the 
possibility of separating the dura from the bone without opening 
the skull; "Strike the skull of a subject with a heavy mallet; on 
dissecting you find the dura mater to be shaken from the skull at 
the point struck. Kepeat the experiment on another subject and 
inject the head minutely with size injection, and you will find a 
clot of injection lying betwixt the skull and the dura mater at the 
part struck, and having an exact resemblance to the coagulum 
found after violent blows on the head." 

The reduplications of the dura extending into the cranial cavity 
between the main portions of the brain are three in number; be- 
tween the hemispheres of the cerebrum we have the falx cerebri, 
between the lobes of the cerebellum we have the falx cerebelli, and 
between the cerebellum and the occipital lobes of the cerebrum 
we have the tentorium cerebelli. The venous sinuses run between 
the layers of the dura which go to make up these three infoldings. 
The tentorium, like other portions of the dura, is a tough, in- 
elastic membrane and, — since its crescentic margin is firmly at- 
tached to the grooves on the occipital bone (the upper edge of the 
petrous portions of the temporal bones and the posterior clinoid 



396 FRACTURES AND DISLOCATIONS 

processes), — it is more or less liable to be torn when the cranium 
changes form during the process of moulding, as it passes through 
the birth canal. Intracranial hemorrhage may then take place 
from the sinuses running between its layers. The falx cerebri 
serves to prevent the hemispheres of the cerebrum from jostling 
each other when the head is struck or moved quickly, and the falx 
cerebelli serves the same purpose for the two halves of the cere- 
bellum. The tentorium cerebelli sustains the weight of the occipi- 
tal lobes and prevents them from pressing on the cerebellum. 

The pia mater is a delicate membrane which invests the surface 
of the brain, contains numerous small vessels which extend per- 
pendicularly into the substance of the cortex. This membrane dips 
down into all the sulci, following the surface of the brain in every 
detail. It also forms the velum interpositum and the choroid 
plexus. 

The arachnoid lies between the dura and the pia, is composed of 
a loose areolar tissue and divides the space between the dura and 
pia into the subdural and the subarachnoid spaces. The arachnoid 
dips into some of the larger sulci, but resembles the dura in this 
respect more than the pia. The thickness of the membrane varies 
considerably in different portions of the brain. On the cerebral 
hemispheres it is thin and delicate, while the part investing the 
pons is heavy and much less vascular. The subarachnoid space 
(between the arachnoid and pia) is quite large at the base of the 
brain and is filled with cerebrospinal fluid. The subarachnoid and 
subdural spaces connect with the ventricular cavities of the brain 
through the foramen of Majendie in the posterior medullary velum 
of the fourth ventricle. The cerebrospinal fluid by its escape into 
the spinal spaces allows a certain amount of displacement of the 
cranial content. 

Vessels of the Membranes. — The vessels running in the dura 
are often partially accommodated by grooves on the inner surface of 
the skull, and this intimate contact between bone and vessel renders 
the latter quite liable to injury when the line of fracture traverses 
these bony channels. The "most important artery in the dura is 
the middle meningeal, a branch of the first portion of the internal 
maxillary artery; it gains entrance to the skull through the fora- 
men spinosum and passes outward onto the internal surface of the 
squamous portion of the temporal, where it divides into an ante- 
rior and posterior branch. The anterior branch passes outward 



FRACTURES OF THE SKULL 397 

and forward, while the course of the posterior branch is outward 
and backward. Both branches are continued onto the inner sur- 
face of the parietal bone. There is considerable normal variation 
in the courses of these two branches after they reach the parietal 
bone, and we have no possible means of ascertaining the exact 
position that they may occupy in a given case. The anterior 
branch, however, will usually be found passing upward and 
slightly baclnvard from a point about one and three quarters inches 
above the zygoma and one and a half inches behind the external 
angular process of the frontal bone. The course of the artery 




Fig. 515. — Internal surface of right half of skull showing courses of middle menin- 
geal artery and lateral sinus. In this case the posterior branch of the artery is 
double and calls attention to the frequency with which anomalies occur in the course 
and distribution of this vessel. A study of this vessel and its anomalies will point 
out the advantages of the osteoplastic method of opening the skull as compared with 
trephining, for the removal of clots. 

from this point is nearly parallel to the coronal suture, running 
from one-half to three quarters of an inch behind it. A trephine 
opening with its center about one inch above the external auditory 
meatus will expose the posterior branch of the middle meningeal. 
In trephining in this region it should be remembered that the skull 
is thin, the internal surface irregular and that the anterior branch 
of the middle meningeal (especially in the region of the pterion) 
may run in a complete bony canal instead of a groove. Kronlein's 
diagram gives the three most frequent sites for the location of 
clots following hemorrhage from this artery. The diagnosis of the 
position of these clots is often difficult, sometimes impossible. The 



398 FRACTURES AND DISLOCATIONS 

most satisfactory method has been found in the osteo-plastic flap 
which exposes enough of the brain to satisfactorily explore its sur- 
face without missing the site of hemorrhage. Meningeal hemor- 
rhage may take place from some of the smaller meningeal arteries 
and occupy regions in the frontal or occipital lobes. A common 
form of meningeal hemorrhage is that arising from small veins. 
A linear fracture mRj divide small veins, and the resulting hemor- 




Fig. 516. — ^View of right half of interior of base of skull showing the courses of the 
middle meningeal artery and lateral sinus. 

rhage, though slow, not infrequently forms a large coagulum. 
In this form of hemorrhage the symptoms are slow in developing 
because it takes a number of hours for the clot to assume sufficient 
size to cause disturbance. In addition to the middle meningeal 
artery, there are also other meningeal arteries of smaller size. 
They are the three meningeals from the ascending pharyngeal : — 
the anterior meningeal from the internal carotid, the posterior 
from the vertebral, and the small meningeal from the internal 



FRACTURES OF THE SKULL 399 

maxillary. These arteries, however, are all of small size and rarely 
the cause of hemorrhage. 

Intracranial Sinuses. — The most common site of meningeal 
hemorrhage, after the middle meningeal artery, is the lateral sinus. 
The walls of the sinnses are formed by a splitting of the dura and 
are lined by an endothelial layer which is continuous with the 
lining membrane of the veins. Sinuses may be the site of throm- 
bosis and suppuration and when ruptured result in intracranial 
hemorrhage ; they should be specially avoided when trephining the 
skull. The superior longitudinal sinus corresponds to a line 
drawn from the glabella to the inion. A line drawn from the in ion 
to a point one and a half inches above the external auditory meatus 
will correspond to the highest part of the lateral sinus where it 
crosses the lambdoid suture. The lateral sinus then curves down- 
ward and forward running on the internal surface of the mastoid 
portion of the temporal. It is joined by the superior petrosal 
sinus at the posterior end of the upper border of petrous portion 
of the temporal and by the inferior petrosal sinus just below the 
jugular foramen after the two sinuses have passed out of the skull. 
The two cavernous sinuses situated on either side of the cella 
Turcica drain the ophthalmic vein, anastomose with each other 
through the circular and transverse sinuses and are themselves 
drained into the lateral sinuses by means of the petrosal sinuses. 
A line drawn perpendicular to the surface of the bone just below 
the inion, if projected into the skull, would correspond to the 
course of the straight sinus. The straight sinus drains the veins 
of Galen and the inferior longitudinal sinus which runs in the 
lower border of the falx cerebri. The blood from the straight 
sinus is drained by one of the lateral sinuses after having been 
emptied into torcular Herophili. The occipital is formed by the 
two marginal sinuses which connect with the sigmoid portion of 
the lateral sinus; it passes upward and empties into the lateral 
sinus, the straight sinus or the torcular Herophili; it establishes 
connection with the deep veins of the neck through the foramen 
magnum. The origin, course and exit from the skull of the twelve 
cranial nerves is of importance in diagnosis but the reader will be 
referred, for this detail, to text-books on the subject. 

Lesions of different portions of the brain will give different 
symptoms according to the function of the region injured. "We 
may divide local injuries of the brain into injuries of the cortical 



400 



FRACTURES AXD DISLOCATIONS 



centers and their tracts, and injuries of the base. For practical 
purposes we may divide the cortex into motor areas, sensory areas, 

Fis. 518. 




Fig. 517. — If., Midpoint of naso-inionic line: L.X., Poirier's line and corresponds 
to Sylvian fissure; I.X., Kocher's equatorial line from- nasion to inion: A.B., German 
base-line and passes through inferior edge of orbit and upper border of external 
auditory meatus. 

Fig. 518. — If., L.X. and I.X. same as in Fig. 517. A line drawn forward and 
downward at an angle of 60 from median plane is known as Kocher's anterior 
meridian and lies over precentral convolution. Kocher's posterior meridian is drawn 
downward and backward 60 from ihe median plane. 

Fig. 519. — Dotted areas correspond to the most frequent sites of meningeal hemor- 
rhage. 

Fig. 520. — Cortical centers. 



and a number of so-called silent areas. The cortex of the brain 
is composed of gray matter which in most regions is disposed in 
five layers. Axis-cylinders from the cells of this gray matter es- 



FRACTURES OF THE SKULL 401 

tablish eomnuniieation between different portions of the cortex 
and between the cortex and the lower centers situated in the base 
of the brain and in the cord. The function of the cortex of the 
brain is to register memories of past experiences. Under certain 
conditions these centers are stimulated and have the capacity of 
reproducing the events which they have registered. Thus stimu- 
lation of the occipital lobe gives us the memory of sights seen, 
stimulation of the temporo-sphenoidal lobe gives us the memories 
of sounds heard, stimulation of the motor area gives us the mem- 
ories of acts performed. It is therefore necessary to know what 
part of the cortex registers certain experiences in order that we 
may be able to tell just what symptoms would be produced by 
injury of a given part of the brain. Conversely, this knowledge 
having been obtained we may be able to state what part of the 
brain has been injured from the observation of certain symptoms. 
The cortex as has been said is divided into certain so-called cen- 
ters. The frontal area is concerned with conscious selective action, 
the Rolandic area with motor memories and the reproduction of 
these memories which results in voluntary motion, while the spinal 
level is concerned with reflex and vegetative automatism. Experi- 
ment on lower animals and observation of diseased and traumatic 
conditions in the human being have determined the function of 
many regions of the cortex, but there are still many areas the 
function of which remains unknown. For obvious reasons the 
more complex and the higher the function of a given area, the 
more difficult it becomes to ascertain the nature of that function. 
The occipital lobe on either side of the calcarine fissure is con- 
cerned with the memories of sights seen ; the temporo-sphenoidal, 
especially the left, with the memory of sounds heard and muscular 
memories; the left angular gyrus with the memory of written 
speech ; the posterior part of the frontal lobe with the memory of 
printed speech; and the third frontal convolution on the left side 
is concerned with the memory of spoken speech. Stereognostic 
sense is located in the parietal lobe. The centers in the Rolandic 
sensori-motor area are disposed inversely (i. e., the centers for the 
head are below those for the upper extremity, etc.). The centers 
for the lower extremity extend onto the mesial surface of the 
hemisphere. Fracture of the vault may injure one or more of 
these areas. If the injury is slight, and the center is not de- 
stroyed, the lesion is said to be irritative and the center overacts. 



402 FRACTURES AND DISLOCATIONS 

If the lesion is more serious and the center is destroyed the func- 
tion of that center is lost. Thus if the Rolandic area is irritated, 
the regions of the body supplied by the corresponding centers are 
thrown into unwonted activity or spasm; but if the lesion is more 
severe, function of the center is lost. This results in loss of mem- 
ory for muscular movements and consequently they cannot be 
voluntarily reproduced. If Broca's convolution is destroyed, the 
memory for the acts connected with motor speech is lost and con- 
sequently the movements of motor speech cannot be reproduced. 
Of recent years, however, there has been some doubt as to the 
function of Broca's convolution, and it is not now thought to be 
so essential to speech as formerly. 

If the lesion penetrates below the cortex, the fibres which asso- 
ciate these centers may be lacerated and the normal communica- 
tion between centers is interfered with. Thus a given center can- 
not be stimulated, as in the normal person, by the activities of an 
associated center. If a center concerned with speech is destroyed 
and the function of that part of the cortex lost the patient is said 
to suffer from aphasia. If the fibres connecting a given cortical 
center with some other cortical center are lacerated the patient is 
said to suffer from intercortical aphasia. If the center destroyed 
is concerned with motor memories the patient has motor aphasia. 
If the centers concerned with registering purely sensory ideas are 
destroyed the patient has sensory aphasia. 

The base of the brain also has centers distributed through its 
substance which preside over various important functions of a 
lower order than those found in the cortex. These centers have 
running through them fibres from the cortex of the brain, so that, 
in case of injury, we have not only symptoms of lesions in these 
lower centers but also symptoms of interruptions of impulses from 
the cortex. 

In the anterior fossa we have the center for smell situated in 
the olfactory lobe. In the middle fossa we have the optic thala- 
mus, the corpora quadrigemina, and the cms. The optic thalamus 
is concerned with emotional facial expression and lesions of this 
body may give rise to athetosis or incoordination of the paralyzed 
hand and pain in the paralyzed limb. The anterior corpora quad- 
rigemina are associated with motion of the eyeballs and acuity of 
vision, the posterior corpora quadrigemina are related to hearing 
and equilibration. The crus contains the nucleus of the third and 



FRACTURES OP THE SKULL 403 

fourth nerves and longitudinal fibres passing from the cerebral 
cortex to the spinal cord. Lesions of this body give a character- 
istic set of symptoms in accordance with the nuclei and fibres 
contained within it: paralysis of the third and fourth nerves will 
deprive all the muscles of the eye of their nerve supply except the 
external rectus; injury to the longitudinal fibres may cause hemi- 
plegia of the opposite side and hemianopsia may be present if the 
adjacent optic tract is injured by pressure. If both crura are 
damaged we have a double hemiplegia with paralysis of the third 
and fourth nerves on both sides, and in some instances optic neu- 
ritis. In the pons we have a continuation of the longitudinal 
fibres of the crura, the thermogenic center, and the nuclei of the 
fifth, sixth, and seventh cranial nerves. Injury to the fibres of 
the crura as they pass through the pons may produce hemiplegia, 
disturbance of the thermogenic center, extremely high tempera- 
ture, and injury to the three cranial nerve nuclei will be followed 
by symptoms peculiar to each nerve. Injury to the nucleus with 
loss of function in each nerve will be as follows: for the fifth, 
hemifacial anesthesia with paralysis of the muscles of mastication ; 
for the sixth, paralysis of the external rectus of the eye ; and for 
the seventh, motor paralysis of the muscles of the face. Bilateral 
symptoms will be present if the lesion involves both sides of the 
pons. 

The usual anatomical division of the bulb into pons and medulla 
is purely artificial. For practical surgical purposes they should 
be considered together. 

The medulla resembles the pons and crura in containing longi- 
tudinal fibres from the cortex together with cranial nerve nuclei. 
The characteristic symptoms of lesions of the medulla will depend 
on the nuclei which it contains. In the upper border of the 
medulla is the nucleus of the eighth cranial nerve which also pro- 
jects into the pons ; in the lower half of the floor of the fourth 
ventricle we have the nuclei of the ninth, tenth, and eleventh 
cranial nerves and at a slightly lower level is found the nucleus 
of the twelfth. The vomiting center, the vaso-motor center and 
numerous other centers governing various functions in the body 
are situated in the bulb, but as yet too little is accurately known 
concerning them to be of considerable surgical value. 

Further back in the posterior fossa we have the cerebellum 
which is concerned in coordinating the various muscular activities 



404 FRACTURES AND DISLOCATIONS 

of the body and in the complex process of equilibration. Another 
function of the cerebellum consists in the peculiar power of im- 
parting the proper degree of force to muscular movements. In- 
jury to the cerebellum may give rise to cerebellar ataxia, obstinate 
projectile vomiting, and various forms of paralyses and anes- 
thesias. The association of the cerebellum with the pons, medulla, 
basal ganglia and cortex is so complete that it is difficult to deter- 
mine the source of these varied symptoms. 

The foregoing enumeration is by no means complete as regards 
location and function of the cortical centers and basal ganglia : 
there is still considerable dispute concerning the functions of these 
centers and there are numerous other centers which as yet remain 
with functions unknown. There are many symptoms occurring in 
head injuries which could be properly explained if we knew more 
of the anatomy and physiology of the brain, but for the present 
the description given will be found of service in roughly deter- 
mining the seat of injury in fracture of the skull. 

Etiology. — Trauma is the cause of fracture of the skull but the 
nature and the degree of violence are so extremely variable that 
the resultant conditions show the greatest differences in detail. 
The trauma may be sustained over a small or large area of the 
skull; the vulnerant body may travel at a high rate of speed (bul- 
let) or at a slow rate (club) ; the violence may be direct or it may 
be transmitted through the spinal column or inferior maxilla. 
The violence may be circumscribed or the head may be squeezed 
or crushed between heavy objects. 

Fracture of the skull constitutes from four to six percent of all 
fractures and possibly more, since we are learning of recent years 
that the milder forms of the condition have only too frequently 
gone unrecognized in the past. Statistics are specially misleading 
in this particular injury, for the following reasons: in the first 
place the most severe cases never reach the hospital because of 
immediate death, and secondly the condition is frequently asso- 
ciated and confused with other injuries ; thirdly, the milder cases 
are often successfully treated at home, and in many cases are not 
classified as fractures because of mistaken diagnoses. For these 
reasons figures derived from a service such as the police surgeon's 
will come nearer the truth, since it includes all classes of fractures 
ranging from the mildest to those immediately fatal. Occupation 
is an important element in the etiologv. Fracture of the skull is 



FRACTURES OF THE SKULL 405 

most frequently found in the male and in middle life. The skull 
in the aged is much more easily fractured than that of the person 
in middle life, but on the other hand those advanced in years are 
not so exposed to injury. 

Mechanism and Pathology. — The various ways in which the skull 
is broken, the manner in which fragments are displaced, and the 
region of the cranium involved have all been subjects of careful 
investigation, and terms, to designate the peculiarities of the con- 
ditions, have been applied. Before considering the mechanism of 
these fractures, it is necessary to again refer to the anatomy with 
respect to the peculiar formations of the vault and base. The 
structure of the skull is peculiar to itself and any attempt to liken 
the manner in which it breaks to that of other objects can at best 
be but incomplete. Circumscribed blows upon the vault of the 
skull commonly produce a local depressed fracture with or without 
injury to the underlying structures. A more extreme blow or 
squeezing of the skull will result in fissures (with or without de- 
pression) which are prone to extend towards and involve the base. 
A certain degree of trauma can be withstood by the vault without 
apparent injury, the shock being absorbed by the natural elas- 
ticity of the bone. If the trauma be a little greater, and the skull 
bent inward sufficiently, the internal table may give and we then 
have a fracture of the inner table alone; a condition frequently 
described in text-books, but rarely seen in practice. A still greater 
trauma results in dissolution of continuity of the entire thickness 
of the bone. On the other hand a blow from a sharp cutting in- 
strument may fracture the outer table while the inner table re- 
mains intact. The skull may be fractured by ''bending" or by 
"bursting." When violence is applied to the skull in a circum- 
scribed region the immediate site of injury is ''bent" inward with 
resultant local fracture which is said to be "fracture by bending." 
When the violence is applied over a larger area and more slowly, 
lines of fracture may be found radiating from the site of impact, 
often involving the base. The action may be likened to the break- 
ing of a nut in a nut-cracker. This form of fracture is spoken 
of as " fracture by bursting ' ' ; the most striking examples of which 
are seen in instances in which the head has been caught and 
crushed between two heavy objects. We often have evidences of 
both the bending and bursting action in a given case. If the skull 
were of a uniform thickness throughout, the mechanism would be 



406 FRACTURES AND DISLOCATIONS 

much easier to determine. As it is we find the peculiarities in 
the structure of the skull directly influence the directions Avhich 
fissures take. When fractures of the vault, between the frontal 
and parietal eminences, involve the base they are frequently ac- 
companied by fissures extending into the middle fossa. When 
fractures posterior to the parietal eminence are accompanied by 
basal fissures they usually extend into the posterior fossa and in 
like manner those anterior to the frontal eminence involve the 
anterior fossa. In gunshot wounds, especially when produced by 
the modern high-pressure bullet, the skull sometimes presents what 
would seem to be an explosive effect similar to that produced by 
shooting through a barrel filled with water. The nature of the 
vulnerant body is an extremely important element, for example; 
the completely jacketed high-velocity rifie ball will usually pene- 
trate cleanly, is not prone to carry in any extraneous materials, 
and the wound is frequently sterile throughout. On the other 
hand a blow from a hammer besides driving a portion of the bone 
into the brain will frequently be found to have carried in hair, 
dirt, or felt, and the wound is therefore much more liable to 
infection. Fracture by contrecoup has been the subject of much 
discussion and although it may be possible for fracture to occur 
at the opposite pole of the head as a result of the meeting of 
vibrations, yet its occurrence has been, to say the least, greatly 
exaggerated. Most of the so-called contrecoup fractures will 
upon further investigation be found to be fractures by bursting 
or the result of a second blow on the head. For example : a man 
sustains a blow on the forehead fracturing the anterior part of 
the skull, falls heavily to the sidewalk and strikes the back of his 
head, producing a second fracture in the occipital region; this 
second fracture is not infrequently considered a fracture by 
contrecoup when in reality it is but the result of a second blow. 
The outline and position assumed by depressed fragments will cor- 
respond, more or less, to the shape of that portion of the vulnerant 
body which has produced the fracture. The terms "gutter," 
"pond," etc., are used to indicate the position of the fragments. 
When the fragment is depressed and only partially detached from 
the remainder of the skull, the unbroken bridge of bone connecting 
the fragment may impart sufficient spring to the depressed portion 
to pinch and secureh^ hold extraneous materials such as hair and 
felt. The injuries inflicted by missiles vary with the nature of 



FRACTURES OF THE SKULL 407 

the projectile, and the Aveapon from which fired. The lead ball 
from an ordinary 32 caliber revolver produces considerable dam- 
age at the point of entrance, and very commonly remains within 
the skull, even when fired at close range. A 38 or 44 caliber is 
much more likely to pass through the skull. The partially jack- 
eted or mushroom bullet usually passes through the head with 
more or less shattering of bone at the wound of entrance, and 
extreme damage, comminution and laceration at the wound of exit. 
The completely jacketed high-velocity projectile, such as used in 
the army, may penetrate the head with a minimum amount of 
trauma; the wound of entrance is small and clean cut, the wound 
of exit is only a trifle larger. Any projectile either low or high 
in velocity is likely to produce extensive comminution when the 
skull is struck a glancing blow. 

Symptoms of Concussion, Contusion, Laceration and Com- 
pression. — The symptoms accompanying fracture of the skull are 
firstly, those of the fracture itself and secondly, those result- 
ing from injury to the encephalon, which may be either general 
or localizing. They will depend upon the extent, nature and posi- 
tion of the injury sustained by the brain. Symptoms of fracture 
are often very meager, and of little importance aside from the 
concomitant brain injury. Before entering upon the s^^mptoms 
occurring in connection with fractures of the skull and injuries 
to the brain, it will be necessary to consider a group of conditions 
which occurs either with or without fracture, namely, — concussion, 
contusion, laceration and compression. At least one and some- 
times all of these four conditions are associated with fracture of 
the skull, but the fact that it is possible for them to be present 
without accompanying injury of the bone renders the diagnosis 
of fracture of the skull more difficult. Concussion and contusion 
of the brain are really the same condition, the difference being one 
of degree. 

Concussion consists of a jarring of the brain-substance which 
results from rapidly putting the head into motion, as by a blow ; 
or by suddenly stopping it while in motion, as in a fall. The 
symptoms of concussion will vary with the severity of the injury. 
When .slight, the patient is momentarily dazed, develops more or 
less of a headache and may suffer from vertigo and nausea. When 
the jarring of the brain-substance is more severe, the patient be- 
comes unconscious, with general muscular relaxation and a cold 



408 FRxVCTURES AND DISLOCATIONS 

clammy skin. There may be loss of sphineteric control at the time 
of the accident, later on the sphincters may fail in reaction, with 
resultant overdistention of the bladder and bowels. There is gen- 
eral systemic depression, the pulse is weak and thready : the pupils 
are, as a rule, equal, with a tendency towards dilatation. Reaction 
to light is present though sluggish. The patient recovers gradu- 
ally from the unconscious state, requiring some hours, in severe 
cases, before complete consciousness and good judgment are re- 
stored. As the patient recovers he is prone to ask many questions, 
which are usually concerning his whereabouts, the nature of the 
accident, etc. The manner in which these questions are put and 
repeated is most characteristic of the condition. For instance, he 
may ask where he is; then what happened to him, how it hap- 
pened; and where some companion may be. These questions are 
as a rule slowly repeated in the same order, regardless of the fact 
that they may have been repeatedly answered. It is a peculiar 
fact that with the loss of memory for the accident and the subse- 
quent unconsciousness, there is also the loss of memory for events 
immediately preceding the accident. This loss of memory pre- 
ceding the accident will cover a period proportionate to the sever- 
ity of the concussion, sometimes many hours, days or even months. 
As memory returns, this blank space is lessened from both ends 
until, with complete recovery, the patient is able to remember 
everything that occurred outside the period of coma. With re- 
turning consciousness the patient is often able to state his name 
before it is possible for him to recollect anything else. It will be 
some time later before he is capable of answering questions in- 
volving numbers, such as his address, date of the month, etc. It 
is important in this regard to see to it that the patient has fully 
regained his good judgment as well as his consciousness, since seri- 
ous consequences may ensue if he be allowed to go about his busi- 
ness unattended. For example, he may be able to state his name, 
give his occupation, tell what business he was about when injured, 
etc., and yet if released may be unable to find his way home or 
may perform some act contrary to good judgment before he has 
thoroughly regained his mental balance and is himself again. It 
is therefore wise to keep him under observation for at least a few 
hours following the accident. 

Contusion. — Contusion as previously stated is but a more severe 
degree of concussion and accordingly we find the symptoms of con- 



FRACTURES OF THE SKULL. 409 

ciission present in exaggerated form. Pathologically there is this 
difference between concussion and contusion: concussion shows no 
characteristic post-mortem findings, while contusion frequently 
shows minute punctate hemorrhages throughout the substance of 
the brain. Like concussion there will be unconsciousness, prostra- 
tion, disturbances in sphincteric control, cold clammy skin, weak 
thready pulse, etc. The unconscious period is prolonged and re- 
covery protracted, so that the condition may cover a period of 
weeks or even longer. Recovery from unconsciousness is slower, 
and in rare instances the condition may be followed by mania end- 
ing in recovery, death or dementia. Protracted and severe head- 
ache is not uncommon and vomiting is often persistent. During 
semiconsciousness, headache is evidenced by the patient putting 
his hand to his head and later when able to talk he complains of 
the pain. If the intracranial disturbance is severe enough to be 
irritative, one or both pupils may show contraction, according to 
the cerebral regions involved. During recovery, which is gradual, 
the patient may develop an active delirium and if not restrained 
may leave his bed and wander about aimlessly. During this semi- 
conscious period he often assumes a perverse, obstinate, mental 
attitude which renders nursing difficult and sometimes even dan- 
gerous. In extreme cases the patient may pass into a typhoid 
state with sordes, coated tongue, sphincteric disturbances, low mut- 
tering delirium, subsultus tendinum, etc. When contusion is se- 
vere or prolonged, localizing symptoms are likely to develop ; the 
condition is then recognized as one of laceration or compression 
as well as contusion. When symptoms of compression develop 
early they are likely to be due to hemorrhage or laceration, but if 
they come on late, edema of the brain is probably the cause. 

Laceration. — Laceration of the brain tissue without fracture 
may be considered an intensified, local contusion and is due to the 
same causes. When it is the direct result of depressed fragments 
or the entrance into the skull of the vulnerant body we find that 
the condition may occur more or less independently of the symp- 
toms which usually accompany concussion, contusion and com- 
pression. Laceration may accompany contusion and concussion 
without giving rise to localizing symptoms if the region of the 
brain involved is not capable of i)roducing peripheral disturbances 
in function. When the region injured is within some of the so- 
called silent areas, we have no localizing symptoms. Contusions 



410 FRACTURES AND DISLOCATIONS 

and lacerations of tlie brain are a frequent accompaniment of frac- 
tures of the base, the most frequent sites being the under surfaces 
of the frontal lobes and the tips of the spheno-temporal lobes. In 
depressed fractures of the vault it is common to find the cortex 
beneath the fragments suffering from laceration. The pulse is 
usually weak and rapid, resembling concussion in this respect; in- 
creased tension and slow pulse are to be expected only when com- 
pression develops. The temperature in both concussion and 
contusion is, as a rule, subnormal but as the conditions merge into 
the more severe grades of brain injury, such as laceration, the 
temperature rises above normal. . 

Compression. — The physical phenomena indicating compression 
of brain tissue vary widely with the location, rapidity and degree 
of pressure. The cranial contents are fluid and semifluid, hence 
the question of intracranial pressure is essentially one of hydro- 
dynamics. The cerebrospinal fluid occupies a considerable space 
between the brain and the skull, especially at the base, and when 
hemorrhage occurs within the skull this fluid is displaced into the 
spinal spaces to make room for the clot within the cranium. 
Under such conditions the capacity of the skull remains the same 
and the fluid nature of the contents precludes actual condensation 
or compression, yet the pressure pervading the entire mass is in- 
creased, accounting to some extent for the symptoms. This 
pressure impedes the circulation within the skull, resulting in 
intracranial anemia, which is in turn compensated for by the 
activity of the vasomotor centers which raise the general blood 
pressure. Hence the slow, high-tension, bounding pulse seen in 
compression of the encephalon. If the pressure be slowly applied, 
allowing the cerebrospinal fluid ample time for displacement, a 
surprisingly large clot may result with but mild symptoms ; on the 
other hand pronounced and rapid symptoms may accompany a 
small quick hemorrhage. The most pronounced symptoms, there- 
fore, accompany large rapid hemorrhages such as occur from the 
middle meningeal artery, while the mildest and slowest of onset 
are seen in cases where a small clot has developed gradually from 
one of the smaller veins. During compression, the intracranial 
pressure will be approximately the same throughout the skull but 
the displacement of cerebral tissue will be greatest surrounding 
the foreign material, decreasing in all directions within the sknll 
inversely as the square of the distance. The region of greatest 



FRACTURES OF THE SKULL 411 

displacement will show the greatest amount of cell injury and 
dissociation between cells, and will therefore be the area to suffer 
most functionally. If the foreign accumulation takes place rap- 
idly the function of the cortex may be destroyed at once, but if 
the pressure is exerted more gradually there will be irritation with 
overaction of the centers, followed by paralysis if the process be 
carried far enough. Accordingly when motor areas are the seat 
of displacement we have spasm of groups of muscles according to 
the cortical regions involved; this overaction or convulsion is fol- 
lowed by paralysis if the pressure is continued and increased. 
Compression may be the result of hemorrhage from the meningeal 
or cerebral vessels, from edema following contusion, from depressed 
fragments of bone and from the forcible introduction of foreign 
bodies through the skull and into the brain. ^ 

Symptoms. — The most common causes of traumatic compression 
are the depression of fragments and hemorrhage from the menin- 
geal vessels, especially the middle meningeal. The same trauma 
which causes compression almost invariably produces concussion, 
and if the concussion does not clear up before the symptoms of 
compression develop, the patient will present the symptoms of both 
conditions simultaneously. A return to the unconscious state dur- 
ing recovery from concussion is therefore a symptom characteristic 
of compression, the conscious or semiconscious interval represents 
a condition of the patient in which he is coming out of the un- 
consciousness of concussion before the clot has assumed sufficient 
size to produce coma from increased intracranial pressure and 
displacement. 

The symptom-complex of fracture of the skull is so variable and 
the subject so extensive that it is difficult to study the numerous 
symptoms in detail, and at the same time keep a clear, concise 
and comprehensive view of the subject as a whole. For this reason 
we will consider first, in tabulated form, the most frequent sj^mp- 
toms which may accompany the condition, after which they will 
be taken up in detail. The same difficulties which confront us in 
the study of these conditions prevail in dealing with the case at 
the bedside, and unless we have some systematized method of pro- 
cedure we are more than likely to overlook some of the symp- 
toms. 



1 Pathological conditions such as tumors, cysts, etc., are not here considered as they 
are not related to fractures, except as sequelse. 



412 FRACTURES AND DISLOCATIONS 

For convenience the symptoms may be divided into local, gen- 
eral and localizing. 

Local symptoms. 

1. Pain in the region of the fracture. 

2. Scalp wounds. 

3. Depressions or fissures in the bone. 

4. Mobility and crepitus. 

5. Escape of blood, cerebrospinal fluid or brain tissue. 

6. Ecchymosis. 

7. Emphysema. 

General symptoms. 

8. Unconsciousness. 

9. Vomiting. 

10. Headache. 

11. Vertigo. 

12. General flaccidity and loss of deep reflexes. 

13. Variations in pulse and blood pressure. 

14. Variations in respiration. 

15. Variations in temperature. 

Localizing symptoms. 

16. Deviations in the positions of the eyes. 

17. Alterations in pupillary reactions. 

18. Local motor and sensory paralyses and disturbances in 

muscular tone. 

19. Disparity in deep reflexes of two sides. 

20. Disparity in temperature of two sides. 

21. Disturbances in higher psychic function. 

22. Aphasias. 

23. Cranial nerve symptoms. 

It is not to be supposed that any given patient will present all 
of the aboA^e tabulated symptoms, and no one symptom will be 
present in all cases. Each patient examined will show a different 
combination of symptoms as a result of the variations in bone and 
brain injury which occur in different instances. Most fractures 
of the vault present a more or less complete set of local symptoms, 
being, as a rule, accompanied by wounds of the scalp. In frac- 
tures of the vault localizing symptoms will be present depending 



FRACTURES OF THE SKULL 



413 



upon whether or not the motor areas have been injnrecl. Frac- 
tnres of the base are less productive of local symptoms, though 
the general symptoms are usually more pronounced. 

Local Symptoms. — 1. Pain in the region of fracture is present 
if the patient is conscious : in other words, pain is present if the 
encephalon is capable of recognizing the afferent impulses which 
constitute pain. In many cases of semiconsciousness pain is indi- 
cated by groaning or by repeatedly carrying the hand to the seat 
of the injury. Pain is present in simple scalp wounds but is not 
as severe as that which results when the skull is fractured and the 
meninges injured. 




Fig. 521. — Depressed fracture of the vault produced by a fragment of an explod- 
ing shell during the Franco-Prussian war. History of severe infection. No untoward 
late results. 



2. The symptoms of scalp ivounds do not necessarily accompany 
those of fracture of the skull, but the frequent association of the 
two conditions in fracture of the vault would render the picture 
misleading if the symptoms of scalp injury were not included 
under the local symptoms of fracture of the skull (see "Scalp 
Wounds, "page 382). 

3. Depressions of hone may sometimes be recognized by inspec- 
tion alone, though the symptom is usually found only by palpa- 
tion and exploration of the scalp wound. Fissures may be present 
radiating from a depression or existing independently, and can be 
recognized only by examination of the bone. 

4. Mobility and crepitus may be present in rare instances but 
are, as a rule, only elicited during exploration of the bones of the 



414 



FRACTURES AND DISLOCATIONS 




rig. 522. — Old depressed fracture in frontal region. Injury sustained during child- 
hood. No symptoms whatever of intracranial disturbance. 




Fig. 523. — Depressed fractui'e of skull in left parietal region of about eighteen 
years' standing. Not followed by any late symptoms. Patient presents himself at this 
time for treatment of slight scalp wound seen at the upper margin of the old depres- 
sion. 



FRACTURES OF THE SKULL 



415 




Fig. 524. — Depressed fracture of the vault without symptoms for over twenty 
years. Of late the patient complains of pain at the seat of fracture followed at 
times by general headache, vertigo and dizziness. An example of the development of 
late symptoms in instances in which depression is allowed to go uncorrected. 




Fig. 525. — Fracture of posterior fossa due to fall on the back of head. No symp- 
toms suggestive of the condition until the day following the injury (nearly twenty-four 
hours). Patient went about his business stating that he was perfectly well and did 
not desire any attention. Death due to intracranial pressure produced by hemorrha-ge 
from a small vein in the posterior fossa .which was torn as it crossed the line of 
fracture. Hemorrhage ultimately covered the base of the brain. Patient found dead 
in bed next morning. Moderate quantity of venous blood had made its escape from 
the nasal cavities during sleep. Line of fracture retouched as the photogi'aph was 
poor, having been taken by the light of a 16 c.p. electric lamp. 



416 



FRACTURES AND DISLOCATIONS 



vault. A fracture may encircle the skull, dividing it into two 
portions, and with such a condition it may be possible to move 




Fio-. 526. — Old depressed fracture of the frontal 
:-emoved. Uneventful recovery. 



Case operated and bone 




Fig. 527. — Fracture running from base to vault and nearly encircling the skull. 
Patient lived a few hours following the injury. Photograph taken shortly after death. 
Lesion result of fall from window. 

one part of the skull on the other, thus producing mobility and 
sometimes crepitus. 



FRACTURES OF THE SKULL 



417 



5. Fracture through the base of the skull may allow the escape 
of hlood or cerebrospinal fluid and rarely brain tissue from the 




Fig. 528. — Severe comminuted depressed fracture of the vault, during operation. 
A. represents a large depressed fragment of bone. B. represents the horseshoe-shaped 
flap turned back to expose the fracture. The arrow to the left is in line with fracture 
above the large fragment. The arrow to the right is in line with the fracture below 
the fragment. The upper portion of the fragment is considerably depressed. 




Fig.- 529. — Example of the explosive effect of the modern high pressure missile at 
close range. Wound inflicted with a 32-20 cartridge fired from a Smith & Wesson 
revolver. (Soft nose bullet.) Picture taken about twenty minutes after injury. Pa- 
tient lived about one hour. 



ears, nose, or mouth according to the region of fracture. In frac- 
ture of the vault these same materials may escape directly through 
the scalp wound or into the tissues of the scalp when the condi- 



418 



FRACTURES AND DISLOCATIONS 



tion is not compound. It should be remembered that a large pro- 
portion of basal fractures result from the extension of a linear frac- 
ture of the vault into the base, and hence are fractures of both 
vault and base. The escape of brain tissue is much more com- 
mon in fracture of the vault than it is when the base alone 
is involved. Hemorrhage is extremely variable in quantity and 
duration. It may be very severe for a few minutes or blood may 
continue to flow in small amounts for a period of days. The flow 
of cerebrospinal fluid is likeh^ to persist for at least some hours, 
usually days, when leakage is once established. It is commonly 




Fig. 530. — Bullet in head. The arrow points to the opening in the skull througl 
which the bullet entered. 



mixed with blood during the first few hours or the first day, after 
which it is likely to become clear and free from accompanying 
hemorrhage. 

6. Ecchymosis beneath the conjunctiva is a common symptom 
in fracture of the anterior fossa and may be accompanied by 
exophthalmos if the collection of blood within the orbit is of any 
considerable quantity. Ecchymosis beneath the eyelids may arise 



FRACTURES OF THE SKULL 



419 




Vig. 531. — Pronoumed :> welling and ecchymosis of both eyes following small scalp 
wound on left side of forehead. Condition suggestive of fracture of the base of the 
skull since there has been no trauma near the patient's right eye to account for its 
swelling and blackening. 




Fig. 532. — Case of severe depressed fracture of the vault. The patient went 
about for ten days without any attention to the condition. He then presented himself 
for medical treatment because of a headache. Parts badly infected. Operation per- 
formed with elevation of the depressed fragments. Recovery. Two years later he 
committed suicide and the calvarium was obtained at autopsy. Patient was a hard 
di'inker and was drunk at the time of the injury, which accounts for his ten days' 
neglect of the fracture. 



420 FRACTURES AND DISLOCATIONS 

from the same causes; it usually spreads outward from the in- 
ternal canthns and is accompanied by subconjunctival ecchymosis. 
Exophthalmos with pronounced swelling and ecchymosis of the 
lids is commonly seen in suicidal gunshot injuries in which the 
revolver has been held to the temple, the ball having passed 
through the skull directly behind the orbits or through their apices. 
Ecch^Tnosis about the mastoids and nape of the neck is not un- 
commonly seen in fracture of the posterior fossa though it rarely 
develops before the first twelve or twenty-four hours. Battle's 
sign consists of ecchymosis following the course of the posterior 
auricular artery and is sometimes seen in fracture of the posterior 
fossa. 

7. Emphysema behind the ear or in the region of the glabella 
sometimes occurs when the fracture opens the mastoid cells or 
frontal sinuses. Under such conditions air is much more likely 
to remain in the tissues if there is no accompanying scalp wound 
to allow its escape. 

General Symptoms. — The general symptoms accompanying 
fracture of the skull are much the same as seen in concussion, 
contusion, laceration and compression previously described. 

8. Unconsciousness is a common state in head injury and usu- 
ally obliterates symptoms which might otherwise be of value in 
diagnosis and treatment. Although unconsciousness accompanies 
most head injuries and is more or less proportionate to the severity 
of the case, yet in exceptional instances it may be of the mildest 
type, or absent, even though the condition be grave. Fractures 
of the base are much more luiiformly accompanied by unconscious- 
ness than are fractures of the vault. The degree of unconscious- 
ness is extremely variable, ranging from cases of momentary 
insensibility to cases in which the coma is profound. Roughly 
speaking the severe cases are accompanied by the more profound 
grades of unconsciousness. The symptom has already been de- 
scribed under the heading of concussion, contusion, laceration and 
compression (page 407). 

9. Vomiting is a symptom which is commonly present in the 
early stages of fracture of the skull though it is not in any way 
pathognomonic, since it regularly occurs in concussion and allied 
conditions w^ien fracture is absent. Vomiting occurs in so many 
conditions that it is of little significance. It is seldom present 
after the first few hours though in severe cases it may persist for 



FRACTURES OF THE SKULL 421 

a considerable period. In rare instances the vomiting may be 
projectile in character and nnassociated with nausea. As a late 
symptom it may occur with cerebral tumor or abscess. 

10. Headache is a common symptom following head injuries of* 
all kinds. A slight blow on the head without disturbances in 
consciousness, or any other symptom, may be followed by headache 
for a day or so. On the other hand, headache may be the most 
pronounced symptom of a serious brain lesion. Headache as a 
late symptom of fracture of the skull is discussed on page 451. 

11. Vertigo is often present though its recognition is frequently 
prevented by other symptoms such as unconsciousness, prostra- 
tion, etc. When persistent it is most often associated with in- 
juries of the cerebellum or disturbances in the end organs or nerve 
tracts leading to the cerebellum. One of the important functions 
of this portion of the brain is equilibration which requires an 
uninterrupted and complete flow of afferent impulses, especially 
from the cochlea, semicircular canals, eye and muscles of the body. 
When the end organs are suddenly thrown out of function or the 
tracts leading from them are interfered with the cerebellum fails 
to receive the necessary data for the performance of its peculiar 
function and the symptoms of vertigo result. Vertigo may fol- 
low excessive impulses from a given region, as well as absence or 
diminution of impulses. Thus, irritative lesions of the semicir- 
cular canals may flood the cerebellum, so to speak, with abnormally 
strong or incorrect impulses so that the function of this portion 
of the brain is disturbed. The conditions in which such dis- 
turbance may occur are legion ; it may be present in mild or severe 
cases, either organic or functional in nature, and hence vertigo 
is a common symptom and is usually of little diagnostic value. It 
rarely persists however if there is no organic lesion present. It 
may be subjective or objective ; the patient feels that he is turn- 
ing, or suffers from the sensation of surrounding objects revolving 
about him. 

12. General flaccidity sometimes including sphincteric relaxation 
is a condition common to all forms of profound coma and will 
therefore be seen in the more severe types of head injury. The 
more sudden and violent the onset of coma the greater the prob- 
ability of involuntary evacuations. 

The deep reflexes may be lost in coma from any cause if the 
unconsciousness is extremely profound. They are absent, there- 



422 FRACTURES AND DISLOCATIONS 

fore, in head injuries of the more severe type. (S^e page 423 
for deep reflexes as a localizing symptom.) 

13. Variations in the pulse and hlood pressure occur as already 
described under concussion and allied conditions (see page 407). 
"When shock alone is present the pulse Avill he rapid and the tension 
low ; when cerebral compression occurs the pressure rises and the 
pulse becomes slow and bounding. A patient in extremis will 
show a weak, rapid, irregular pulse regardless of the presence 
of compression. 

14. Variations in respiration are common in head injuries. Any 
profound unconsciousness may be accompanied by stertorous 
breathing especially if the person occupies the, dorsal recumbent 
position. It is common in deep sleep and is due to relaxation 
of the soft palate and lips. It may be sighing, languid, explosive, 
irregular, shall oav, deep, etc. Rhythmic disturbances are sometimes 
seen, as exemplified in Cheyne-Stokes ' respiration in which the 
pectoral excursion increases with each respiration until the patient 
presents the symptoms of pronounced dyspnoea, when the respira- 
tor^^ excursions grow progressively weaker until a condition of 
apncea is again reached ; — after a short period of quiescence the 
cycle is repeated. In some instances irritation of the respiratory 
center produces a pronounced snorting with each inspiration. The 
more severe cases of head injury are often accompanied by the 
more pronounced disturbances in respiration. 

15. Variations in temperature occur commonly in head injuries. 
Simple concussion is accompanied by lowering of temperature in 
most cases. Laceration of the brain tissue, contusion and compres- 
sion are attended by rise in temperature if the condition is at all 
severe. Variations in temperature are considered among the gen- 
eral symptoms, yet an extreme elevation of temperature (106°- 
109° F.) accompanies pontine lesions and hence the temperature 
becomes a localizing symptom. 

Localizing Symptoms. — The localizing symptoms occurring in 
head injuries are extremely variable, moreover unconsciousness 
obscures many of these symptoms early in the condition. 

16. Deviations in the positions of the eyes are common and 
show considerable variation. The eye of the injured side may be 
turned in any direction regardless of the position of the opposite 
eye. External and internal strabismus or an upward turning of 
the eye are common. Turning of the head and both eves toward 



FRACTURES OF THE SKULL 423 

the side of the lesion is not infrequently found and is known as 
"conjugate deviation." Nystagmus is sometimes observed. 

17. Alterations in pupillary reactions and size usually accompany 
fracture of the base of the skull. The most common disturbance is 
that- of dilatation of the pupil with loss or diminution in reaction 
on the same side as the lesion. The pupil of the opposite side is 
often normal in size and reaction. Pronounced contraction usually 
means an irritative lesion of the third nerve but is rarely seen. 
Loss of reaction in one or both pupils is a grave symptom. When 
the optic nerve or tract anterior to the oculo-motor nuclei is torn 
the pupillary reflex is abolished through destruction of the afferent 
arc of the reflex arc. Wernicke's hemianoptic pupillary reaction 
may be present in cortical visual lesions.^ 

18. Local paralyses and disturbances in muscidar tone may be 
present if the cortex has been injured, monoplegias, hemiplegias 
or crossed paralyses may be present according to the site of the 
lesion. The paralysis may be overlooked in the unconscious state 
if the surgeon is not observant. If the cortical lesion is irritative 
the corresponding peripheral area will show increased muscular 
tone, twdtching or spasm. AVhen the pressure becomes sufficient 
to throw the involved area of the cortex out of function paralysis 
develops. Sensory losses frequently occur over areas correspond- 
ing in extent with the motor paralysis, the anesthesia usually 
preceding the paretic condition. 

19. Disparity in deep reflexes. — When paralysis exists in an 
extremity following cortical injuries the deep reflexes are dimin- 
ished or lost throughout the paralyzed area. If the cortical lesion 
is irritative as indicated by increased muscular tone, twitchings or 
spasm, the deep reflexes in the member presided over (i. e., the con- 



1 The author has observed an irregularity in the rotundity of the pupil in about 
a dozen instances of fracture of the posterior fossa with cerebellar injury, though he 
cannot state definitely at the present time that this pupillary peculiarity is necessarily 
indicative of cerebellar disturbances. Dilatation of the upper outer quadrant of the 
iris has been present in most instances (in one case this same portion of the iris 
showed more contraction than the remaining three quarters of the pupillary circum- 
ference). The same irregularity, though much less pronounced, occurs at times in al- 
coholism, and the oval pupil is reported as one of the symptoms of Gerlier's disease. 
Alcohol has a distinct influence on the cerebellum as is indicated by the ataxic condi- 
tion of drunkenness and the symptoms of Gerlier's disease all point unmistakably to 
cerebellar disturbances. The nerve supply to the dilating fibres of the upper ouler 
quadrant of the iris are from a different portion of the sympathetic than those inner- 
vating the remainder of the pupil ; the clinical observations therefore are, to some ex- 
tent, in accordance with the anatomical facts. Further observation and experiment 
will determine the value of the symptom. 



424 FRACTURES AND DISLOCATIONS 

tralateral half of face, arm or leg) will be exaggerated. Thus 
an arm or leg with an irritative cortical lesion in the opposite hem- 
isphere of the cerebrum will show an increase of the deep reflexes 
when compared with the sound limb. If the cortical lesion be 
paralytic the deep reflexes will be less than those of the opposite 
unaffected member, or what is still more common thev will be 
entirely wanting early in the condition. 

20. The temperature of the paralyzed lirnl) will usually show 
a reduction of one or one and a half degrees below that of the op- 
posite member. Twenty-four to forty-eight hours following the 
injury the temperature in the affected member is likely to rise a 
degree or so above normal, being higher than the temperature 
observed in the opposite extremity. These surface temperatures 
are best taken by the surgeon himself, to secure the most accurate 
results.^ 

21. Disturbance in the higher psychic function (judgment, 
reasoning, concentration, etc.) is sometimes attendant upon lesions 
of the frontal lobes. The disturbances in function however are by 
no means constantly proportionate to the extent and severity of 
the injury. Severe damage may occur in the frontal region with 
loss of brain tissue and still not be followed by any appreciable 
disturbance in the reasoning powers of the individual, yet injury 
in this region is at times attended by distinct clouding of the 
intellect or disturbed mentality. Damage to the frontal lobes is 
much more likely to be followed by functional impairment in chil- 
dren than in adults and is probably due to the fact that the injury 
is sustained during the developmental period. 

22. Aphasias will seldom be noted early following fracture of 
the skull because of unconsciousness. Later on the patient may 
show auditory aphasia, visual aphasia, motor aphasia or graphic 
motor aphasia or any combination of these defects. Auditory and 
visual aphasia most frequently occur together. The center for au- 
ditory word memories is in the left temporal lobe, that for visual 
word memories is in the left angular gyrus, that for motor mem- 
ories is in the foot of the third left frontal convolution, and the 
remaining center for graphic motor memories is probably located in 
the second left frontal convolution near the centers for the right 



1 In taking surface temperature the skin should be thoroughly dried with a pledget 
of cotton and the thermometer held in place with an adhesive strap for five minutes 
actual count by the watch. Alcohol should not be used in cleaning and drying the skin 
because of the refrigerant action attendant upon evaporation. 



FRACTURES OF THE SKULL 425 

hand. In left-lianded persons these speech centers are located on 
the opposite side. Anj^ of these various types of aphasias may be 
present according to the site of the cortical lesion or the damage 
done to the tracts leading to or from them. Inasmuch as these 
different functions are all more or less interdependent we will 
see the different types of aphasias occurring together in varying 
degrees and combinations. The stereognostic sense is located in 
the parietal lobe and injury to this region will be followed by 
astereognosis. 

23. Organic lesions and functional disturbances in the cranial 
nerves commonly accompany fracture of the skull, especially the 
base, and the symptoms will vary with the function of the nerve. 
Many of the cranial nerve functions are sensory and therefore 
subjective in nature so that the symptoms of disturbed or destroyed 
function are not recognizable durirg unconsciousness. Any of the 
cranial nerves may be injured in fracture of the base or their 
centers may be irritated or destroyed in lesions involving the bulb. 
The function of these nerves may be disturbed by shock or by 
intracranial pressure without organic lesion in either center or 
nerve so that restoration of function is complete when the intra- 
cranial pressure is removed or concussion passes off. Complete 
loss of function usually means permanent impairment; slight loss 
of function is often followed by complete recovery. Loss of func- 
tion in some of the cranial nerves may come on some time follow- 
ing the accident especially if meningitis develops. It is seldom 
that a single cranial nerve is injured. 

I. Consciousness is necessary to determine the presence or ab- 
sence of smell, hence disturbances in this sense cannot be recog- 
nized early. Fracture of the anterior fossa, hemorrhage between 
the olfactory bulb and the cribriform plate, raising and tearing 
the bulb from the olfactory nerves, hemorrhage within the bulb 
or above it with pressure, or thrust wounds through the nose may 
injure or destroy this sense. 

II. The optic nerve is sometimes injured in fractures of the 
base. The cella Turcica seems to be frequently involved in frac- 
tures traversing the base and the close proximity of the optic 
nerves, chiasm and tracts accounts for blindness and some forms 
of impaired vision which may follow basal fracture. Injury as 
the nerve passes through the optic foramen is probably most com- 
mon. Blindness may be noted as soon as the patient regains con- 



426 FRACTURES AND DISLOCATIONS 

sciousness and is due to hemorrhage within or about the nerve or 
laceration of the nerve itself. Blindness coming on some time 
after the injury has been noted in some cases of fracture of the 
base and may be due to pressure from callus formation when the 
fracture passes through the optic foramen. (See "Alterations in 
Pupillary Eeactions, " page 423.) 

Ill, IV, and VI. The third, fourth and sixth cranial nerves 
have long intracranial courses beneath the brain and are therefore 
especially exposed to injury in fractures of the base. The third 
nerve is more commonly injured in one of its branches than is the 
entire nerve. Paralysis of all the branches of the motor oculi is 
followed by external strabismus and dilatation of the pupil. The 
eyeball assumes different positions when different branches of the 
third are involved. Paralysis of the sixth is followed by internal 
strabismus. Paralysis of the fourth nerve is more difficult to recog- 
nize ; it may be accompanied by diplopia or looking downward. 

V. The fifth nerve is the sensory nerve of the face, and in- 
nervates the muscles of mastication. Anesthesia of the face fol- 
lows injury of this nerve and if the damage is permanent, herpes, 
keratitis neuroparalytica and trophic disturbances may follow in 
the skin of the face. The motor fibres supplying the muscles of 
mastication travel with the third or inferior maxillary divi- 
sion. 

VII. The seventh supplies all the muscles of the face and the 
buccinator. Injury to this nerve is attended by the characteristic 
symptoms of Bell's palsy. It is the most frequently injured of 
the twelve cranial nerves. 

VIII. The eighth cranial nerve is the nerve of hearing and when 
torn across will be followed by deafness. Fracture through the 
petrous portion of the temporal may injure the organs of hearing 
or clots may collect within the tympanum and thus disturb hear- 
ing without injury to the nerve itself. The bone conduction test 
should be the only one, therefore, on which to base a diagnosis 
of injury to the nerve. Irritation of the eighth nerve is likely 
to be accompanied by persistent tinnitus and aural vertigo as well 
as impaired hearing. 

IX. X, and XL The ninth, tenth and eleventh cranial nerves 
have a short intracranial course and in their exit from the skull 
occupy the middle portion of the jugular foramen with the lateral 
sinus on one side and the inferior petrosal sinus on the other. 



FRACTURES OF THE SKULL 427 

The large size of the foramen through which they pass and their 
short intracranial courses render them less liable to injury than 
most other nerves passing through the base of the skull. Their 
nuclei, however, situated in the medulla are very commonly tem- 
porarily disturbed in function by increased intracranial pressure 
or raised blood tension, as evidenced by the respiratory, cardiac 
and gastric disturbances occurring in head injuries. A traumatic 
lesion which seriously injures or destroys these centers is usually 
immediately fatal. Injuries of the ninth nerve, as evidenced by 
disturbances in swallowing, rarely occur in head injuries. Sen- 
sory and motor disturbances in the larynx, disturbances of the 
stomach and intestines, disturbance in heart action and respiration, 
may accompany injury to or disturbed function of the vagus. 

The spinal -accessory supplies the sterno-mastoid and upper por- 
tion of the trapezius on the same side and paralysis of these two 
muscles follows injury to the eleventh cranial nerve. 

XII. The tivelfth cranial nerve is rarely injured in fracture of 
the skull. Paralysis of half the tongue followed by trophic changes 
in the paretic side of the organ and disturbances in the innerva- 
tion of certain muscles of the neck are the symptoms. 

Diagnosis. — The diagnosis of fracture of the skull may be so evi- 
dent that one cannot fail to recognize the condition, but on the 
other hand the symptoms may, in some cases, be so obscured or 
indefinite that it is impossible to state whether or not fracture 
exists. 

A searching history and thorough examination are the two es- 
sentials for proper diagnosis. 

The history should be taken in systematic order, inquiry with 
proper deductions being made on the following points : nature of 
accident, manner in which injury was sustained with estimation 
of degree of trauma, onset and degree of unconsciousness if present, 
symptoms displayed prior to observation by the surgeon. Was 
there spasm? Was there hemorrhage from mouth, nose or ears! 
If blood is found in the external auditory canal, did it run into 
ear from an adjoining wound of face or scalp, or did it first ap- 
pear in the ear? What were the patient's surroundings? Was 
there probability of poison having been given to, or taken by him ? 
Did previous disease exist, such as nephritis or diabetes? Has he 
been subject to fits of any kind ? What has been the previous state 
of his health ? Has he or any of his family been subject to nervous 



428 FRACTURES AND DISLOCATIONS 

diseases or conditions in which unconsciousness took place ? AYhat 
is his age? 

Examinaiion. — If patient is unconscious determine as far as 
possible the depth of coma, examine pupils, note reaction to light, 
compare size of two pupils, and circularity of each. Note the 
position of eyes, and position of head with relation to position of 
eyes, note motility of eyeballs, examine for paralyses or spasm of 
extremities or face. Compare deep reflexes of two sides, test for 
Babinski's sign, patella clonus, ankle clonus. Observe general 
muscular tone and condition of skin, variations in pulse and blood 
pressure, abnormalities in respiration. Compare temperature of 
two sides. Examine scalp carefully for evidences of trauma ; if 
wounds of the scalp or hematomata are present they should be 
explored and enlarged if necessary, with due precaution for asep- 
sis. The scalp should be shaved and the wound treated as de- 
scribed previously under the heading of scalp wounds. Cranial 
sutures should not be mistaken for linear fractures while inspect- 
ing the bottom of the wound, and rents in the pericranium should 
not be confused with depression, when palpation is employed. 
Use probe rarely, with caution and only after sterilization in flame. 
Determine mobility and crepitus when present. Note nature and 
amount of fluids escaping from one or both ears. Pure blood or 
blood mixed with serum, liquor Cotunii, or cerebrospinal fluid may 
escape from the ear, nose, or mouth. It would seem an easy mat- 
ter to recognize cerebrospinal fluid when mixed Avith blood, but the 
condition seems to have been simulated by large quantities of 
serum or liquor Cotunii, and it is often a difficult matter to state 
definitely that a given fluid escaping from the skull contains cere- 
brospinal fluid. When, however, the fluid is waterj^, low in al- 
bumin and high in sodium chlorid one may feel reasonably sure 
that cerebrospinal fluid is present. The face and scalp should 
be examined for ecchymosis and emphysema. Ecchymosis about 
the eye with adjoining bruise or abrasion of the face is indicative 
only of superficial injury. Ecchymosis about the eye spreading 
toward the external canthus from the inner angle and accompanied 
by conjunctival ecchymosis and no proximate trauma of the face 
is indicative of fracture of the base, the blood coming from within 
the orbit. 

A chart should be kept and the symptoms entered in the order of 
their appearance. Special note should be made of the tempera- 



FRACTURES OF THE SKULL 429 

tiire, respiration, pulse, blood pressure and depth of unconscious- 
ness. Early unconsciousness is usually the result of concussion, 
prolonged unconsciousness is suggestive of contusion, laceration 
or compression. A return to the unconscious state is almost al- 
ways due to intracranial hemorrhage. Rise of blood pressure with 
slow pulse usually indicates hemorrhage. Palpation alone is too 
inaccurate to be dependable in determining the blood pressure ; 
we should use the sphygmomanometer. Before drawing conclu- 
sions on the blood pressure we should know the condition of the 
arteries and the age of the patient, at least approximately. For 
example : a tension of 170 m.m. in a man of sixty with arterio- 
sclerosis would not be as indicative of hemorrhage as the same 
pressure in a man of twenty-five with normal elastic arter- 
ies. 

Albumin and sugar may make their appearance in the urine a 
short time following head injuries and for this reason the patient 
should be catheterized at the earliest possible moment and the 
urine analyzed to determine the condition of the urine excreted 
prior to the accident. This urinalysis when compared with later 
tests may indicate the source of sugar or albumin when present. 
The value of localizing symptoms in diagnosis will best be appre- 
ciated by reviewing these symptoms on page 412. 

A careful consideration of the facts disclosed in the history and 
determined by examination will in most cases afford sufficient data 
for a correct diagnosis. Many of the symptoms of fracture which 
are of value are subjective in nature or appear late in the course 
of the case and are not available at the usual time of the first ex- 
amination. 

Differential Diagnosis. — Fracture of the skull with brain injury 
is usually associated with a more or less complete loss of conscious- 
ness and it will be necessary in avoiding mistakes to exclude other 
forms of coma. A mistaken diagnosis may deprive the patient 
of a much needed decompressive operation or may subject him to 
dangerous surgical procedure when the coma is due to toxic or 
other conditions not amenable to surgery. It will therefore be 
necessary to consider other forms of unconsciousness that we may 
systematically exclude them before making a diagnosis of brain 
injury. The following classification, like most classifications, is 
by no means ideal, yet it will form a working basis on which to 
consider the causes of coma. 



430 FRACTURES AND DISLOCATIONS 

A. Coma due to temporary circulatory disturbance. 

1. Syncope. 

2. Shock. 

3. Cerebral congestion. 

4. Cerebral anemia. 

B. Coma due to medicinal and other extraneous poisons cir- 

culating in the blood. 

5. Alcoholic coma. 

6. Opium coma. 

7. Phenol coma. 

8. Chloral coma. 

9. Asphyxia from illuminating gas. 

10. Asphyxia from carbon monoxid. 

11. Ptomaine coma. 

12. Lead coma. 

13. Belladonna and its alkaloids. 

14. Hyocyamus and its alkaloids. 

C. Coma following chronic disease and due to toxins arising 

within the body. 

15. Uremic coma. 

16. Diabetic coma. 

D. Keflex comas and those preceding or following acute in- 

fections. 

17. Convulsions and coma sometimes precede the acute exan- 

themata in childhood. 

18. Reflex convulsions and coma may accompany dentitional 

and gastro-intestinal disturbances in children. 

19. Comatose conditions may accompany acute infections such 

as typhoid, pneumonia, etc. 

E. Diseases and neuroses of the central nervous system are not 

infrequently accompanied by coma. 

20. Hysteria and feigning. 

21. Epilepsy. 

22. Apoplexy. 

Cerebral hemorrhage. 
Cerebral embolism. 
Cerebral thrombosis. 



FRACTURES OF THE SKULL 431 

23. Cerebral syphilis. 

24. Cerebral meningitis. 

25. Abscess of brain. 

26. Tnmor of brain. 

27. Epileptiform and apoplectiform attacks due to cerebral 

arterial disease. 

A. Coma Due to Temporary Circulatory Disturbance. — 
1. Syncope. — The essential of syncope is the fact that it is tran- 
sient ; lo^yering of the head or shock, such as is produced by cold 
water, is accompanied by the return of consciousness within a 
few minutes. Pallor of the skin and mucous membranes, with 
cold, clammy, relaxed skin are constant ; pupils are equal and 
dilated, vrith reaction to light sluggish or absent; pulse weak, 
rapid and sometimes perceptible only in the larger vessels ; tem- 
perature subnormal ; respiration weak, shallow and quiet. The 
characteristic symptoms of other forms of coma are absent. In 
simple syncope, not due to organic heart disease, the attack is 
evanescent. Disease of the heart or vessels may produce an un- 
consciousness more profound and prolonged in character, with a 
tendency toward cyanosis. Hysterical syncope is likely to be re- 
peated; it lacks the essential symptoms of simple syncope. The 
color of the skin and mucous membranes and the pulse are un- 
changed, unless the attack is accompanied by severe muscular exer- 
tion, as seen in hysterical convulsions. 

2. Shock. — Shock and cerebral concussion are so closely asso- 
ciated that, for practical purposes, it is useless to distinguish 
closely between them. Shock is a condition accompanying cere- 
bral concussion though it may occur independently of it, as seen 
following hemorrhage. In the milder forms of shock conscious- 
ness may be practically undisturbed, while in severer forms coma 
is often profound. Pulse is weak, rapid, often irregular and some- 
times slow; respiration shallow, frequent and usually quiet; the 
functional activities of the entire body are lessened; the tempera- 
ture falls below normal early in the condition and the blood 
pressure may be markedly reduced. The symptoms usually last 
for a few hours ; recovery is the rule except in the severer forms. 
Vomiting frequently occurs as the patient is regaining conscious- 
ness. Interruption in recovery, prolonged or delayed shock or an 
increase in the symptoms after the first few hours usually indicates 



432 FRACTURES AND DISLOCATIONS 

serious complications. In simple shock or concussion localizing 
symptoms are absent. 

3. Cerehral congestion. — The most common cause of congestion 
of the brain is isolation. The onset of coma is usually gradual and 
preceded by headache and delirium. The arterial tension is high ; 
pulse rapid, full and strong; respiration often rapid, deep and 
noisy : temperature usually a degree or two above normal. The 
history of exposure to a torrid sun, absence of trauma, and local 
and localizing symptoms differentiate the condition from brain 
injury. 

4. Cerehral anemia. — Aside from syncope and shock anemia of 
the brain is commonl}^ the result of exsanguination. The diagnosis 
is made on the history of loss of blood and the symptoms, which 
resemble shock. Any degree of loss of consciousness may be pres- 
ent from slight lethargy to deep coma. Delirium and convulsions 
may occur when the hemorrhage has been sudden and profuse. 

B. Coma Due to ^Medicinal and Other Extraneous Poisons 
Circulating in the Blood. — Unconsciousness resulting from acute 
poisoning has always been a source of difficulty in diagnosing un- 
conscious states due to head injury. Simple drunkenness is prob- 
ably the most common cause of abnormal unconsciousness and the 
frequency with which this condition is seen, together with the pre- 
disposition these cases show to accidental injury, makes the subject 
an important one. Persons attempting suicide not infrequently 
take more than one poison to accomplish the result or may combine 
poison with self-infiicted injury, such as cutting the throat or 
jumping from a window. The diagnosis under such conditions is 
rendered more difficult and accordingly the surgeon should not be 
satisfied as soon as a single cause of unconsciousness is found. 
Of one hundred consecutive poison cases treated by the author 
thirty-four were due to opium or morphine, twenty to phenol, nine 
to alcohol, seven to ptomaine, six to chloroform, four to strychnine, 
four to chloral, three to bichlorid of mercury, two to illuminating 
gas, three were complicated by hysteria, in four the nature of the 
poison was unknown and in nineteen cases the poison was unusual 
and has been classified under the heading "miscellaneous." Deep 
coma was present in thirtj^-six of the hundred cases, death resulted 
almost immediateh' in five cases and in thirteen instances the cause 
of poisoning or coma was multiple. Simple cases of alcoholism 
were not included among these cases except as a complication of 



FRACTURES OF THE SKULL 433 

some other poison or unless the case presented serious symptoms. 
Simple cases of hysteria are also excluded except as a complica- 
tion of poison. In the majority of these cases, by close examina- 
tion of the patient's surroundings or by inquiry from those 
present, it was possible to determine the nature of the poison in- 
gested, independently of the symptoms presented by the case. 
These figures indicate to some extent the difficulty sometimes ex- 
perienced in determining the cause of unconsciousness and illus- 
trate the necessity of being familiar with the symptoms occurring 
in the various forms of poisoning. In this respect we have to con- 
sider not only the most frequent forms of poisoning but those most 
frequently producing a comatose condition which might be mistaken 
for the unconsciousness following head injury. 

5. Alcoholic coma. — The condition is so common that the symp- 
toms are usuall}^ recognized without difficulty as being due to 
alcohol. The symptoms however are so similar to the general 
symptoms occurring in head injury that it is sometimes only by the 
most careful and persistent observation that the existence of the 
two conditions may be recognized when they occur together. There 
are two types of alcoholic coma which deserve mention ; the first 
is the acute type occurring in persons not habitually accustomed to 
the use of alcohol and the second is that of acute drunkenness in 
a chronic drunkard. In the first we have simply the acute effects 
of the drug, taken in over-dose, while in the second we have the 
acute effects of the drug added to the condition of chronic alco- 
holism. The generally unkempt condition, bloated face, chronic- 
ally inflamed eyes, reddened nose, putty-like complexion with edema 
beneath the lower eyelids (usually indicating chronic nephritis) 
all point to chronic alcoholism. This appearance gives the exam- 
iner a portion of the history of the case at a glance. The depth 
of coma varies in acute alcoholism according to the amount of al- 
cohol ingested. It is usually possible to rouse the patient by sud- 
denly producing pain such as may be inflicted by supraorbital 
pressure, by pressure behind the ramus of the jaw, by pressing a 
lead pencil into the w^eb of the fingers or by means of the electric 
brush. When aroused he is usually noisy and abusive until the 
annoyance is removed, when he lapses back into his drunken sleep 
or stupor. If he can be made to talk, even if only a little, the 
characteristic thick speech of alcoholism is recognized. Some- 
times the coma is extremely profound so that it is not possible to 



434 FRACTURES AND DISLOCATIONS 

rouse him by any ordinary means and we are obliged to resort to 
the electric brush, Eepeated stimuli will often produce results 
when a single application of the brush or of supraorbital pres- 
sure would elicit no response. Alcohol may be detected on the 
patient's breath. The clean fresh breath of simple acute alcohol- 
ism is quite different from the characteristically foul and offensive 
odor emanating from the mouth of a chronic drunkard. The pu- 
pils are usually equal, slightly dilated and respond sluggishl}^ to 
light, though they may be either moderately contracted or dilated. 
The temperature is usually normal, unless he has been exposed to 
weather as frequently occurs in drunkenness. The pulse is as a 
rule increased slightly in rate and low in volume: Slight cyanosis 
commonly occurs about the face and neck. The respiration is 
often blowing or stertorous. The skin is relaxed and covered wdth 
cold sweat. The deep reflexes are present though reduced. The 
appearance of the patient, alcoholic breath, condition of the pupils, 
respiration, temperature, pulse and nature of the coma together 
with the absence of local and localizing symptoms will usually serve 
to differentiate alcoholic coma from brain injury. Another fre- 
quent form of unconsciousness (to be taken up later on page 443) 
is that of apoplectiform and epileptiform conA^ilsions (commonly 
spoken of as ''whiskey fits"), which occur in advanced cases of 
chronic alcoholism. 

6. Opium coma. — Opium or its alkaloids is one of the common 
methods of suicide, and the length of time between ingestion and 
coma is ample, even when large doses are taken, to permit the pa- 
tient already bent on self-destruction to meet with accident. The 
condition due to opium poisoning is characteristic; the pulse is 
slow, usually weak; respiration extremely slow (5 or 6 to the min- 
ute), usually noisy from the relaxed condition of the soft palate 
and lips ; temperature generally normal, though it may be slightly 
subnormal and may rise preceding dissolution. Pupils are strongly 
contracted and usuall}^ show little or no tendency to react to light. 
Inquiry into the surroundings of the case will generally disclose 
the cause of the coma in the form of an empty labeled vial or box. 
The history of the case, the characteristic symptom-complex, the 
absence of local and localizing symptoms will readily differentiate 
the condition from brain injury. 

7. Phenol coma. — Poisoning from carbolic acid, especially large 



FRACTURES OF THE SKULD 435 

doses, produces unconsciousness within a short time of ingestion. 
The skin is pale, cold, clammy and relaxed ; respiration stertorous ; 
pulse weak and rapid; temperature may be subnormal; pupils 
usually equal, dilated and either sluggish or rigid. The character- 
istic white eschar of carbolic acid is seen about the lips and within 
the mouth, and the characteristic odor of the poison permeates the 
room. 

8. Chloral coma. — The most characteristic symptom of poison- 
ing from chloral is the early and pronounced cyanosis which 
usually precedes loss of consciousness. When coma develops it 
rapidly becomes profound ; the temperature is lowered from one or 
two to several degrees below normal ; the pulse is at first soft and 
slow, becoming rapid and irregular as the patient passes into a more 
critical state; the pupils are moderately contracted early in the 
condition, becoming dilated as the coma becomes more profound. 
The patient is thoroughly relaxed and the respiration is slow. 
The functions of the entire body are greatly depressed. The pro- 
nounced lividity, deep coma, muscular relaxation and the absence 
of local and localizing symptoms serve to differentiate the condition 
from brain injury. 

9. Asphyxia from illuminating gas. — The patient smells strongly 
of the gas. During the coma the respiration is slow and blowy, 
pulse slow and weak, pupils sluggish but reactive to light until 
shortly before death. Temperature subnormal. The history of 
the case or the odor of gas emanating from the patient will be 
sufficient to determine the cause of unconsciousness. 

10. Asphyxia from carhon monoxid. — In poisoning from carbon 
monoxid the clinical picture is quite different from asphyxia re- 
sulting from illuminating gas. The patient is rigid and tremors 
pass over the body, there is slight cyanosis and frequently a light 
froth at the mouth. Respiration labored, pulse weak and irreg- 
ular. The eyes are sometimes open and the patient may roll 
them about giving the impression of consciousness, when in reality 
he knows nothing of his surroundings. Vomiting is common and 
on analysis of the vomitus, carbon monoxid is found. Skin relaxed 
and covered with cold perspiration. The history of the case hav- 
ing been exposed to carbon monoxid and the peculiar symptoms 
will determine the diagnosis. 

11. Ptomaine poisoning. — In poisoning by ptomaines the onset 



436 FRACTURES AND DISLOCATIONS 

is gradual, accompanied by severe gastro-intestinal disturbances. 
Coma is not common and is late in development. The history alone 
should serve to differentiate the condition. 

12. Coma from lead poisoning occurs specially in those persons 
whose occupation exposes them to the fumes of the metal. The 
onset of coma is gradual and preceded by convulsions, colic, purg- 
ing and vomiting. The presence of lead in the urine and the blue 
line on the gums will distinguish the condition from other forms 
of coma even if no history is obtainable. 

13. Co7na from belladonna is often preceded by convulsions and 
delirium. The temperature is raised, respiration slow and deep 
until the patient is in extremis, pulse rapid. Pupils are widely 
dilated, skin hot and dry and covered with the characteristic rash 
produced by the drug. 

14. Hyocyamus and its oMaloids dilate the pupil though not as 
widely or quickly as belladonna. Extreme dryness of the mouth 
and throat is present, with flushed face. The pulse and respira- 
tion are slow and the temperature may show a rise though the 
diaphoresis produced by the drug would tend to reduce this again. 
Incoordination is present before the patient loses consciousness 
and later on pronounced muscular relaxation is present. 

C. Coma Following Chronic Disease and Due to Toxins 
Arising Within the Body. — Nephritis and diabetes are two con- 
ditions which we should never fail to consider when examining 
unconscious cases. The enfeebled condition which these two dis- 
eases often produce predispose the sufferer, especially in cities, to 
accident. But, on the other hand, the fact that albumin or sugar 
is found in the urine of an unconscious case should not cause us 
to jump at the conclusion that the cause of coma is necessarily the 
unconsciousness produced by the disease. Other forms of un- 
consciousness should be excluded as far as possible, the patient 
carefully watched for further developments, and the proper treat- 
ment for diabetic or uremic coma instituted. 

15. Uremic coma. — Uremic coma is usually of gradual onset, be- 
ing often preceded by headache and malaise. Delirium and con- 
vulsions are usually present preceding absolute unconsciousness. 
Albumin and tube casts are found in the urine but their presence 
aside from a history of nephritis or other symptoms of the disease 
is of little diagnostic value since they occur so frequently in injury 



FRACTURES OF THE SKULL 437 

and diseases of the brain and other conditions. If the disease has 
advanced far enough to produce coma, we are almost sure to find 
other symptoms of the disease such as edema of the legs, edema 
beneath the eyes, the facies peculiar to chronic nephritis and the 
characteristic urinous odor to the breath. Uremia may simulate 
the symptoms of brain injury more closely than any other condi- 
tion. Variations of the pupils, apparent paralysis of the extrem- 
ities or of one side of the face, ocular deviations, or conjugate 
deviation of the head and eyes not infrequently occur and may 
lead one, especially if wounds or abrasions of the scalp exist, into 
making a diagnosis of intracranial hemorrhage or brain injury 
when the symptoms are due entirely to uremia. These symptoms, 
however, are found to change in character and position (a sup- 
posed paralysis shifting from one member to another) which is not 
the case in organic lesions of the brain. A careful history of the 
case, the lack of permanency in the false localizing symptoms and 
the presence of other evidences of advanced nephritis will usually 
suffice in making the differential diagnosis. 

16. Dialetic coma. — In coma due to diabetes the onset is vari- 
able; it may come on rapidly following exertion or it may be 
gradual and preceded by nausea and vomiting. Sugar in large 
quantities is found in the urine though this is by no means pathog- 
nomonic. It is one thing to determine that the patient has dia- 
betes and quite another to prove that the unconsciousness is a 
direct result of the disease. Acetones are of more value in diag- 
nosis than in sugar. The blood picture in diabetes is often typ- 
ical ; hyperglycemia and polycythemia are usually present. 
Moderate leukocytosis and beta-oxybutyric acid are almost con- 
stant in diabetic coma. A high percentage of fat is often found 
in the blood and the red corpuscles fail to take the stain as in 
normal blood. Boils or carbuncles, or scars indicating their pre- 
vious existence, are sometimes found on the skin. The harsh dry 
skin, sometimes showing diabetic bronzing, localized gangrene as- 
sociated with arteriosclerosis, onychia, etc., when present suggest 
diabetes. The breath often has a peculiar sweet, heavy odor, char- 
acteristic of diabetes. The history of the case, examination of the 
blood and urine, and the presence of some of the sj-mptoms of 
diabetes above mentioned will usually disclose the cause of the 
coma. In examining the blood of these cases it is essential to 



438 FRACTURES AND DISLOCATIONS 

draw off a sufficient quantity (8 or 10 c.c.) to enable the laboratory 
man to conduct a satisfactory^ chemical and microscopical exam- 
ination. 

D. Keflex Comas and Those Preceding or Following Acute 
Infections. 

17. The acute exanthemata of childhood are sometimes ushered 
in by convulsions and coma. This is particularly true of scarlet 
fever. The eruption of scarlet fever makes its appearance Avithin 
twenty-four hours, following which the coma passes off. The tem- 
perature in the preeruptive stage is usualh^ high (104 or 105). 
It is often impossible to make a positive diagnosis before the erup- 
tion makes its appearance, yet by inquiring into the history of 
exposure to infection and the absence of cranial trauma together 
with the history of one or tAvo convulsions folloAved by coma and 
high temperature should lead us to suspect an acute infection. 

18i. Coma due to dentitional or gastrointestinal disturbances in 
children Avill usually give a history pointing to these disorders 
prior to the onset of unconsciousness. Coma is usually preceded 
by convulsions. The temperature is loAver and the pulse sloAver 
than usually found preceding the acute exanthemata. 

19. Comatose states developing during acute infections usually 
come on late in the course of the disease and in most cases the pre- 
ceding history will be all that is necessary for differentiation. 
The loAv muttering delirium of typhoid and similar conditions is 
too characteristic to be mistaken. 

E, Diseases and Neuroses of the Central Nervous System 
are not Infrequently Accompanied by Coma and it is often 
difficult to determine whether the patient fell unconscious because 
of the disease or AAdiether unconsciousness is the result of head in- 
jury sustained in an accidental fall. 

20. The co7na of hysteria usually occurs in Avomen, comes on 
rapidly and may be preceded or alternate Avith delirium. The pa- 
tient frequently falls with the onset of unconsciousness, but it Avill 
be noted, usually falls in a conA^enient place and is not injured in 
the act. The pulse respiration and temperature are normal ex- 
cept in instances in AAdiich there has been severe muscular exertion 
such as occurs in hysteria major. In such cases the respiration 
may be rapid but is free and not stertorous, and the temperature 
may show a degree or so of elevation with a slightly accelerated 
pulse. When the examiner raises the eyelid for inspection, the 



FRACTURES OF THE SKULL 439 

eyeball presents a characteristic rolling movement, with attempt on 
the part of the patient to keep the pupil under cover of the margin 
of the lid. Muscular resistance from the orbicularis palpebrarum 
is also encountered in raising the eyelid. The pupils are usually 
normal and react to light ; muscular exertion, however, may cause 
them to be slightly dilated. Suddenly inflicted pain will usually 
elicit prompt response and often results in the surgeon being 
roundly scored for his trouble. In rare instances however the 
patient will withstand the most severe supra-orbital pressure, re- 
sponding only with the use of the electric brush. Evacuations of 
the bladder or bowel never occur in hysterical coma. 

A clever malingerer may simulate any form of coma but for- 
tunately those who attempt feigning are usually not well enough 
versed in symptomatology to produce a consistent picture. The 
eyeball is never fixed in the malingerer and the pupil reacts nor- 
mally to light. Sudden and repeated pain will elicit response as 
in hysteria. Convulsions and rigidity are much less common than 
in hysteria. 

The exhibition of apomorphine will cause the hysteric or feigner 
to forget about his unconsciousness as soon as he becomes actively 
engaged with the effects of the drug. Other causes of unconscious- 
ness may readily be excluded by the absence of the symptoms which 
accompany real coma and the fact that the patient can be com- 
pletely roused. 

21. TJnconscioiisness due to epilepsy. — The ordinary epileptic fit 
is of short duration, in fact the surgeon seldom arrives on the scene 
in time to witness the attack. If the history of the case can be 
had or the onset of the attack is observed there will be little diffi- 
culty in differentiating the condition from other causes of coma. 
The patient often presents a semicomatose condition following the 
attack or may show delirium or become actively maniacal. The 
tongue is often bitten during an attack and in man}^ cases old 
scars are present on the tongue indicating injury to the organ in 
previous convulsions. In old cases of epilepsy it is common to 
find numerous old scars on the scalp and face, the result of injuries 
sustained in previous attacks. The history of the case, the short 
duration of the unconsciousness and the absence of localizing symp- 
toms will distinguish the condition from other forms of coma. In 
status epilepticus, however, one attack follows so closely upon an- 
other that unconsciousness is continuous and it mav be almost im- 



440 FRACTURES AND DISLOCATIONS 

possible without the history of the case to differentiate between 
this condition and an acute cerebral lesion. It should be remem- 
bered, in this connection, that intracranial hemorrhage may result 
from an epileptic attack and the manner in which these cases fall 
may produce fracture of the skull or meningeal hemorrhage. 

22. Apoplexy. — Differentiation between apoplexy and traumatic 
brain injury may under some circumstances be extremely difficult. 
The history of the case should be inquired into most carefully 
with special reference to the manner in which coma developed. 
Apoplexy is one form of brain injury and hence the symptoms will 
be similar to those occurring as a result of brain injury from 
external trauma. When the cortex is irritated, as occurs in men- 
ingeal hemorrhage or pressure from fragments, the paralysis is 
more likely to be preceded by local spasm ; — when the damage 
is done to the tracts leading from the cortex as is usual in apo- 
plexy, the paralytic symptoms are preceded by only slight spasm 
if convulsive movements are present at all. The local symptoms 
of brain injury should be carefully looked for and excluded if 
there is any question as to the cause or site of the hemorrhage. 

Cerebral embolism, thrombosis and hemorrhage are included 
under the heading of apoplexy, yet the three conditions are so 
different in some respects that their characteristics will have to 
be considered separately. Cerelral embolism is seen oftenest be- 
tween the ages of thirty and fifty, occurs during physical activity 
or when strain is thrown upon the heart from any cause. A 
previous history of articular rheumatism or chorea complicated by 
cardiac disease is usually obtainable. If the heart is auscultated 
murmurs will usually be noted, since the condition is most often 
the result of vegetative endocarditis involving the mitral valve. 
The onset of coma is very sudden, being caused, as a rule, by 
occlusion of the middle cerebral artery. The lesion may be irrita- 
tive or paralytic with corresponding motor increase or motor 
loss. The cerebral edema surrounding the area of anemia usually 
clears up within a few days, with corresponding diminution in the 
extent of the symptoms. The only part of the brain suffering 
permanent damage is that portion previously supplied by the 
occluded artery. Abscess or softening frequently follows. The 
previous history of the case, the presence of endocarditis, the onset 
of coma, and the absence of cranial trauma will usually be suffi- 
cient to differentiate. 



FRACTURES OF THE SKULL 441 

Cerebral ihi^omhosis occurs most frequently between the ages of 
twenty and forty or after sixty-five. Wlien it occurs between 
twenty and forty it is usually due to syphilis, and other symptoms 
of this disease will be present. Other debilitating conditions how- 
ever may be responsible for thrombosis, such as tuberculosis, can- 
cer, primaiy anemia, hemorrhage, diabetes and pregnancy. When 
thrombosis takes place after sixty-five it is almost invariably due 
to arteriosclerosis. It usually occurs during sleep or similar states 
of inactivit}^ in which the blood pressure is lowered or the viscosity 
of the blood increased. The history usually shows previous at- 
tacks of dizziness or periods of weakness or paresthesia in an ex- 
tremity lasting a few hours or days. The onset of coma is, as a 
rule, gradual and progressive and since the pathologic process most 
frequently occurs in the cortical veins the symptoms are at first 
irritative in character. Aside from weakness, the common aura 
consist of attacks of vertigo, aphasia, local peripheral muscular 
twitchings or spasm, or disturbances in sight. The lesion produces 
more damage than takes place in embolism and the symptoms in- 
dicate progress as the thrombus extends in the vessel, including 
additional branches. In some instances the thrombus may extend 
around under the base of the brain involving centers of the op- 
posite side. Thrombosis in the aged is a frequent source of cere- 
bral softening; abscess is relatively rare. The gradual onset of 
unconsciousness, progressive nature of the localizing symptoms, 
lowered blood pressure, and the pre^vious history of the case 
should differentiate the condition from traumatic head injury. 

Cerebral hemorrhage most often occurs between the ages of 
forty and sixty. It may take place prior to forty in persons suf- 
fering from premature arteriosclerosis or in conditions which 
predispose to arterial disease or sudden elevation of blood pressure. 
The onset is, as a rule, sudden and the cerebral damage is done at 
once ; the usual seat is the lenticulo-striate artery with accompany- 
ing injury to the internal capsule which results in a hemiplegic 
syndrome. If the hemorrhage is sufficient to break into and flood 
the ventricles the symptoms will be bilateral from the first and 
usually terminate fatally. In the common form of cerebral hemor- 
rhage the patient falls as if struck down, and becomes rapidly un- 
conscious with turgescence of the face and neck. Hemiplegia, 
variations in respiration, flaccidity, sphincteric disturbances and 
conjugate deviation, are some of the symptoms which may occur 



442 FRACTURES AND DISLOCATIONS 

in both apoplexy and fracture of the skull with cortical pressure, 
so that it is impossible in some cases to distinguish between the 
two conditions b}^ the general and localizing symptoms alone. 
The similarity in the localizing symptoms of the two conditions is 
due to the similarity in the lesions. In apoplexy however the 
paralysis is more likely to involve the entire side (i. e., hemiplegia) 
because of the small territory occupied by the fibres as they pass 
through the internal capsule ; in fracture of the skull it would 
require an unusually large clot or area of depressed bone to in- 
clude all the cortical centers for the entire opposite side of the 
body. In apoplexy the extent and degree of paralysis rarely in- 
crease, because the damage to the internal capsule is completed 
at the time of the stroke ; in meningeal hemorrhage it is not un- 
common to see the region of paralysis extend and become more 
pronounced as the clot grows larger, involves more centers and 
produces greater pressure. Monoplegias therefore are more com- 
mon in cortical lesions than in cerebral hemorrhage. ]Monoplegic 
forms of cerebral hemorrhage however are sometimes seen in in- 
stances in which some small artery other than the lenticulo-striate 
is ruptured producing paretic or irritative symptoms according 
to the seat of hemorrhage. The ingravescent form of cerebral 
hemorrhage is extremely rare, the symptoms are gradual and pro- 
gressive in onset, and it usually terminates within a few days. 

The similarity in the two conditions may be extremely confusing 
at times, especially if an apoplectic has sustained a scalp wound or 
other head injury in the fall accompanying the stroke. Most 
careful inquiry -should be made into the history of the ease and 
the onset of unconsciousness. A careful examination of the head 
for the local symptoms of fracture of the skull will often clear 
the diagnosis in doubtful cases. Fracture of the skull with local- 
izing symptoms usually shows more pronounced and earlier pupil- 
lary inequalities than occur in cerebral hemorrhage. 

23. Cerebral syphilis usually occurs between the ages of twenty- 
five and fifty. When coma develops in the course of this disease 
it is usually slowh^ progressive and not deep at the onset. Severe 
headache, especially during the afternoon and evening, pain in 
the shin bones, monocular palsies and the symptoms of cerebral 
thrombosis above referred to commonly precede loss of conscious- 
ness. Other symptoms of syphilis are likely to be present if the 
coma is due to this disease. In some instances a definite history 



FRACTURES OF THE SKULD 443 

of specific infection is obtainable but on the other hand the de- 
termination of syphilis should not lead us to consider this the cause 
of coma without a thorough examination for and exclusion of frac- 
ture of the skull, especially in cases which are known to have met 
with accident. In doubtful cases the Wassermann blood-test should 
be made. 

24. Cerebral meningiiis. — It is uncommon for cerebral menin- 
gitis and cerebral trauma to be associated or confused. Acute 
cerebral meningitis is usually caused by the pneumococcus, 
"Weichelbaum 's meningococcus, or occurs as a part of other acute 
infectious processes especially in childhood. The history of the 
disease preceding unconsciousness is almost invariably obtainable. 
Headache, vertigo, chills or general convulsions precede the rapidly 
deepening coma. Rigidity of the neck muscles with retraction of 
the head is present and if the patient is not absolutely uncon- 
scious, motion of the head will be resisted and cause him to cry 
out. Opisthotonos develops when the spinal membranes become 
involved. The temperature is usually raised though it may be 
subnormal from the onset. The pulse is slow and irregular and 
the respiration increased. Unilateral convulsions may occur. The 
leukocyte count is high. Lumbar puncture is of great value in 
diagnosis. The history of the case, characteristic symptoms, and 
absence of head trauma will usually render the diagnosis easy. 

25. Abscess of the hrain. — Abscess of the brain may occur at 
any age. Two-fifths of the cases are the result of suppurative 
otitis media ; suppurative processes within the chest are responsible 
for a large proportion of the remaining three-fifths. The usual 
early symptoms resemble those of embolism. The middle stage of 
cerebral abscess is quiescent. The third stage develops when rup- 
ture occurs. Absolute coma occurs late and is gradual in onset 
except when it accompanies rupture and then the symptoms simu- 
late those occurring in both meningitis and cerebral hemorrhage. 

26. Tumor of the Irain. — The history shows headache, cerebral 
vomiting, choked disc, and a slow pulse. The onset of coma is 
slow. "When the history can be obtained the condition should 
never be mistaken for brain trauma. 

27. Apoplectiform and epileptiform convulsions occur chiefly in 
arterial diseases of the brain such as seen in alcoholism, uremia, 
paretic dementia, tumor of the brain and disseminated sclerosis. 
The most common form is that occurring in chronic alcoholism. 



444 FRACTURES AND DISLOCATIONS 

The essentials of the condition are the convulsions followed by 
coma, in some cases, with symptoms which at first appear as local- 
izing symptoms but are evanescent in character. The history of 
previous disease and the transitory character of the symptoms 
will render the diagnosis easy. 

Treatment. — Each case must be considered by itself, with special 
reference to the different symptoms displayed. For example : a 
given case may show a scalp wound and bony depression in the 
region of the middle meningeal artery with profuse and dangerous 
hemorrhage, so that operation with elevation of the fragments and 
hemostasis is the prime requisite of treatment. Another case may 
show the most profound shock without signs of, increased intra- 
cranial pressure, the condition being such that the added physio- 
logical insult of operation could have only a fatal outcome if 
performed before reaction takes place. In this type of case stimu- 
lation is indicated regardless of localizing symptoms in order that 
the patient may regain sufficient resistance to withstand the neces- 
sary surgical procedure. Still another case may show but little 
shock and only semiconsciousness, with symptoms of increasing 
intracranial pressure and paralysis indicating the region of cortical 
damage. Under such circumstances expectant treatment might 
soon see the patient in such a state of collapse that operation would 
be useless, or if this did not occur the chances of complete cortical 
recovery might be reduced with every hour of delay. The most 
seasoned surgical judgment and acumen are necessary to deter- 
mine when to operate and when to leave the patient surgically 
alone. In the treatment of fracture of the skull we must keep 
in mind the unfavorable late symptoms and sequels which so often 
follow head injuries, especially when unoperated. 

If the condition of the patient does not call for immediate op- 
eration he should be put to bed and measures instituted for the 
alleviation of shock. Hot water bottles or some other form of 
artificial heat is essential in the treatment, but the greatest care 
should be exercised to avoid burning the patient, since with un- 
consciousness the protective pain and temperature sense is absent. 
The patient may be wrapped in blankets previously warmed by 
the fire. The electric heat blanket is of great advantage, but is 
usually available only in hospitals. It is essential that a chart be 
begun as soon as possible: it should contain records of the pulse, 
respiration and temperature at frequent and regular intervals; 



FRACTURES OF THE SKULL 445 

pupillary changes and alterations in the depth of unconsciousness, 
especially a return to the unconscious state after a lucid interval, 
should be noted. If general or local spasms occur they should be 
entered, and when the necessary apparatus is at hand records of 
the blood pressure should be made every hour or every two hours 
until the necessity of operative intervention is determined. The 
need of intelligent and competent observation and nursing is too 
apparent to require special mention. 

No hard and fast rule can be laid down as to the use of stimu- 
lants and sedatives; it will be necessary to watch the patient care- 
full}' and use drugs as indicated. Strychnine sulphate is a 
valuable stimulant but must be used with due regard for the pos- 
sible harm it may accomplish in intracranial hemorrhage. In 
some cases the collapse may be so critical that stimulation is de- 
manded to avert death, even though there are indications of 
increased intracranial tension. In such instances stimulation may 
render operation possible, thus affording the surgeon opportunity 
for the removal of meningeal clot. Nitroglycerine, in some cases, 
will minimize the danger which may accompany the use of str3^ch- 
nine. Pain or extreme restlessness may call for the exhibition of 
opium, though it is usually unwise to use this drug in head in- 
juries, especially before the diagnosis is properly established. We 
may otherwise obscure symptoms of the greatest importance ; thus 
a. return to the unconscious state, a most significant happening, 
might not be recognized if the patient had just previously received 
a hypodermic injection of morphine. Bromides, chloral and 
codeine are at times useful. In cases of suspected fracture or 
those in which the fracture is diagnosed but operation is not 
deemed advisable, the patient should be kept at rest in bed for 
at least ten days and carefully watched for untoward symptoms. 
A chart should be kept, as previously described, for the purpose 
of accurately determining the course the case is taking. Absolute 
rest and quiet are essential. If the patient is unconscious suffi- 
ciently long to allow the bladder to become distended the catheter 
should be used at regular intervals. 

Fracture of the skull may be rendered compound by scalp 
wounds or by the line of fracture in the base establishing com- 
munication with the nasal or oral cavities, or by involvement of 
the petrous portion of the temporal, and when such is the case 
measures should be instituted to prevent, as far as possible, the 



446 FRACTURES AND DISLOCATIONS 

passage of infection from these cavities to the meninges, and no 
form of treatment is permissible which produces an increased 
pressure (either fluid or gaseous) within these cavities. 

The Ear. — Discharges of blood or serum from the ear call for 
a loose, copious gauze dressing which will absorb the fluids as fast 
as they come from the external auditory canal. The common 
practice of douching the canal with antiseptics is pernicious, since 
by this means infection is more often carried inward than is steri- 
lization accomplished. The canal should not be plugged with 
cotton, as commonly practiced, since this can only tend to dam 
the fluids back instead of allowing their free and prompt escape. 
If clots of blood form within the external auditory meatus they 
should be removed with a sterile ear-hook so that the canal ma}^ 
be kept open. Fracture of the base, allowing the escape of blood 
within the cranium or into the petrous portion of the temporal, 
is much more favorable in outlook if this blood makes its escape 
through the ear. 

The upper part of the nasal cavity and of the naso-pharynx are 
sometimes the seat of basal fractures which establish communi- 
cation between these cavities and the meninges. When such is the 
case, as commonly indicated by hemorrhage or the escape of 
cerebrospinal fluid, the nose and mouth should receive the most 
careful attention. The nose should be kept free and clean by the 
removal of clots forming in the lower part of the nose. Alkaline 
washes, when properly used, may facilitate the removal of these 
clots, but violent douchings or syringings should be avoided, lest 
they carry infection into or through the line of fracture. For 
similar reasons the patient should not be allowed to blow his nose, 
and if coughing occurs it must be controlled by sedatives. Scre- 
atus will draw the secretions through the posterior nares and, 
since it is accompanied by the same result, a negative air pressure 
within the nasal cavities is to be recommended instead of blowing 
the nose. Hemorrhage from the nose, unless severe, does not call 
for checking, and plugging of the nostrils only results in the 
accumulation of foul and infectious clots within the nasal cavities. 
The mouth should be frequently washed out and the teeth cleansed 
with potassium chlorate tooth paste. The cleansing and treatment 
of scalp Avounds has already been described; when flssures or de- 
pressions exist at the bottom of the wound irrigation is contra- 
indicated. 



FRACTURES OF THE SKULL 



447 



Operative Treatment. — Operative treatment is called for; — in 
the treatment of scalp wounds, for the elevation of depressed frag- 
ments in either simple or compound fracture of the vault, for 
alleviation of meningeal hemorrhage, for the removal of foreign 
bodies within the skull, for the correction of secondary complica- 
tions such as cortical irritation resulting from old scars, and for 
the treatment of tumors, abscesses or softening. In depression of 
the vault it is often possible to elevate and remove the fragments 
with a heavy rat-tooth forceps ; but in other instances it may be 
necessary to trephine on the solid side of one of the margins of 
the depression, to introduce an elevator beneath the fragments. A 




Figr. 534. 



Fig. 533. — Diagram indicating the steps in opening the skull by means of an 
osteoplastic flap. 1, 2, 3 and 4 indicate the positions of trephine openings. Solid 
lines indicate division of skull. Line 3-4 indicates where the flap is turned back. 
Dotted line indicates skin incision. 

Fig. 534. — Shows the motor area exposed when the flap is turned back. 



simple fissure without localizing symptoms or indications of intra- 
cranial pressure does not necessarily call for opening of the skull, 
but in many cases the safest plan will be the exclusion of menin- 
geal complication by operative intervention. Of the various meth- 
ods, however, which have been employed for the removal of a 
meningeal clot, the osteoplastic flap is the most satisfactory. It is 
often difficult to accurately determine the site of the hemorrhage, 
even when localizing symptoms are present, and if an opening in 
the skull no larger than that produced by the ordinary trephine is 
made, the chances of failure in locating the clot are many. The 
change in recent years from simple trephining to the use of the 



448 FRACTURES AND DISLOCATIONS 

osteoplastic flap has materially reduced the percentage of operative 
failures. In making an osteoplastic flap a U-shaped incision with 
the convexity upward is made through the scalp and down to the 
bone, the skull is exposed and two small trephine openings are 
made at the upper angles of the quadrilateral section of bone to 
be displaced. A grooved director is then introduced into one of 




Fig. 535. — DeYilbiss bone-cutting forceps used in making the osteoplastic flap of 
skull and scalp. 

the openings and passed between the dura and the skull in the 
direction of the opening in the adjoining angle; by this means 
a Gigli wire saw is passed from one opening to the other and the 
bone between the two cut with the divider in place to protect the 
meninges. If the upper border of the bone flap is beveled at 
the expense of the inner table, while being cut with the saw, it 
will prevent subsequent inward displacement. The vertical sides 




Fig. 536. — Small trephine employed in making an osteoplastic flap. The open- 
ing made with this instrument may be used to introduce the Gigli saw, or a bone- 
cutting forceps such as the DeVilbiss may be used. (See Fig. 535.) 

of the bone flap are then' made by cutting the skull with DeVilbiss 
forceps, beginning at the trephine openings. After the three sides 
are completed the base is broken and the flap turned back. The 
DeVilbiss cutting forceps may be used instead of the saw in con- 
necting the trephine openings, the bone having been previously 
separated from the underlying dura. Those skilled in the use of 



FRACTURES OF THE SKULL 449 

the chisel and mallet divide the bone with considerable facility, 
though this procedure is not to be recommended because of the 
shock so commonly produced by the hammering. (For the course 
of the middle meningeal artery and common sites of meningeal 
hemorrhage, see ''Surgical Anatomy," page 396.) After the flap 
has been made and turned back the clot should be removed with 
the least possible trauma to the underlying brain. The artery 
from which the hemorrhage occurred is to be secured and ligated. 
Subdural clots or bleeding may be present, necessitating the open- 
ing of the dura to reach the collection of blood. In closing the 
wound the dural edges should be carefully approximated with fine 
suture material after all hemorrhage has been properly controlled. 
In cases of marked increased intracranial tension it may be im- 
possible to bring the edges of the dura together, or if such is done, 
the object of the operation is to some extent defeated, if it has 
been performed for decompression. In such instances the dural 
defect may be provided for by the transplantation of a section of 
fascia lata. This prevents adhesions between the brain and scalp 
and at the same time allows an increase in intracranial capacity 
Plastic sliding operations on the scalp may be performed when the 
osteoplastic flap cannot be brought back into accurate apposition 
because of extrusion of the brain and dura. Lumbar puncture 
will facilitate closure of the scalp and skull in an otherwise diffi- 
cult case and is attended by less danger if the skull is open at 
the time the cerebrospinal fluid is withdrawn. Gushing 's cross- 
bow incision may be employed in opening the posterior fossa, 
though the results of decompressive operations in this region have 
not been as satisfactory as one might wish. The positions of the 
sinuses in this part of the skull must be kept in mind when op- 
erating in this region. 

Prognosis. — The prognosis of head injuries is as varied as the 
subject itself. The outlook will depend largely upon the damage 
sustained by the cranial contents at the time of the accident and, 
inasmuch as it is sometimes most difficult to determine the extent 
and severity of this damage, it will be proportionately hard to 
state just what the outcome may be. In addition to the traumatic 
elements we will have to consider the chances of infection and 
meningitis when the fracture is compound. It is next to impossi- 
ble to state in a given case whether or not the patient will in the 
future develop traumatic epilepsy, suffer from chronic headache, 



450 FRACTURES AND DISLOCATIONS 

vertigo and other late symptoms, or that he will or will not develop 
cerebral tumor, abscess, gumma or softening. In a general way 
it may be stated that the more severe the trauma, and the more 
pronounced the symptoms, the greater the danger of an early, 
fatal termination. The prognosis as to life is good in cases which 
survive the first forty-eight hours following the injury. Rigidity 
of the pupils, especially in dilatation, is commonly followed by 
death. Pronounced disturbances in respiration, temperature and 
pulse whether early or late in the case, render the prognosis grave. 
The mortality and the development of sequelae have been materi- 
ally reduced by operation in selected cases. Fracture of the base 
more often produces death than fracture of the vault. Of frac- 
tures of the base those involving the posterior fossa have the high- 
est mortality, those of the anterior fossa the lowest, while fractures 
of the middle fossa occupy an intermediate place. This difference 
in mortality is largely due to the positions of the important basal 
ganglia, and to the fact that hemorrhage into the anterior or mid- 
dle fossae usually makes its escape without difficulty through the 
mouth, nose or ears. i\Ieningitis more commonly follows fracture 
of the anterior and middle fossae, though the dangers from this 
complication by no means equal the deadly effect of pent-up hem- 
orrhage within the posterior fossa. The development of new and 
significant symptoms during the course of the case may so alter 
the general aspect in diagnosis, treatment and prognosis that it 
will be unwise for the surgeon to make any definite forecast early 
in the condition. A most valuable aid in prognosis will be found 
in a carefully kept and complete chart which points accurately to 
changes occurring in the ease and shows whether the symptoms are 
increasing in severity, or, on the other hand, are becoming less 
pronounced. 

Late Symptoms and Sequelae Following Head Injuries. — The 
immediate recovery and the after-effects in fracture of the skull 
do not bear any constant relation to each other, nor are the late 
conditions developing in the course of the case necessarily propor- 
tionate to the extent and severity of the original damage. 

The symptoms of tumor, gumma or abscess of the brain may 
make their appearance months or even years after the original 
injury, following an interval of apparent recovery. -In other in- 
stances the symptoms of the sequelae may develop before the pa- 



FRACTURES OF THE SKULL 451 

tient lias recovered from the acute condition of fracture of the 
skull. 

The unfortunate condition of some of these patients is known 
to those who have attended large clinics for any considerable 
period. The head pains, epileptic convulsions, subjective sensory 
disturbances, psychic changes or paresthesis often unfit the sufferer 
for the sociologic demands of his surroundings, and he haunts the 
clinics or passes from one surgeon to another with the persistent 
hope that some new operation or different type of surgical pro- 
cedure may afford him relief. The peculiar way in which these 
patients attempt to figure out the details of intracranial derange- 
ment and their fixed opinions concerning the manner in which the 
surgeon should correct the trouble, are often characteristic. Epi- 
lepsy following fracture of the skull is not uncommon and often 
assumes the Jacksonian type. When the convulsions are focal in 
character and have not been allowed to persist for a period of 
more than two years the chances of recovery, as a result of op- 
erative intervention, are good if the causative cortical irritation 
is corrected or the area of the cortex in which the convulsion 
begins, is removed. When the non-focal form of epilepsy follows 
fracture of the skull it is not so easily controlled, the treatment 
being, as a rule, medical. 

Chronic headache often begins in, or is confined to, the region 
of the original injury and may be dependent upon cortical irri- 
tation. When such is the case, operations for its relief may be 
successful, as in focal epilepsy. In other instances the headache 
is general and the outlook for surgical relief is not so hopeful. 
Pain in the nerves of the scalp, which is sometimes produced by 
cicatricial contraction, or pain in some of the cranial nerves, as 
a result of injury, is not, strictly speaking, headache, and should 
be dealt with according to the peculiarities of the individual case. 
Chronic headaches following fracture of the skull deserve the most 
careful neurological study in order that the cause may be deter- 
mined, when possible, and relief afforded. 

Vomiting, vertigo, and disturbances in hearing are sometimes 
persistent and extremely distressing to the patient. Little in the 
way of radical treatment can be accomplished for these conditions ; 
sedatives, depressants and proper hygienic surroundings are about 
all that can be done for their relief, with the hope that they will 



452 FRACTURES AND DISLOCATIONS 

in time lessen in degree and finally disappear. When these symp- 
toms occur as a result of cerebral abscess, tumor or softening, the 
treatment becomes that of the causative lesion. Psychic changes 
are not infrequently observed following fractures of the skull, 
particularly in injury to the frontal lobes. The extent of the 
frontal lobes, however, and the variability in the proportion exist- 
ing between lesion and symptoms renders the subject of localiza- 
tion extremely difficult unless local symptoms exist pointing to the 
exact region of damage, and even in instances in which a visible 
depression on the forehead indicates the site of fracture and corti- 
cal displacement, the 'results of operation are by no means uni- 
formly satisfactory. 

The patient may show a simple weakness of intellect, the com- 
prehension being dull and slow, or he may present an irritability 
and temperamental change entirely foreign to his disposition prior 
to the accident. Lassitude and aversion to either physical or 
mental activity are common among the psychic changes. It not 
uncommonly happens that the patient is persistently possessed of 
abnormal fears and apprehensions regarding his physical welfare, 
domestic relations or business responsibilities. The fear of failure 
is sometimes such an obsession that the patient refuses to even 
attempt anything in the way of resuming his former occupation. 
It should not be understood that such fears are without any real 
foundation in fact, yet when they do exist it is usually noted that 
the real degree of unfitness is by no means proportionate to his 
own sense of incapacity. In rare instances insanity may follow. 



CHAPTER XXXII. 

FRACTURES OF THE STERNUM. 

Surgical Anatomy. — The sternum is rarely fractured. Firstly, 
because of the protection afforded by the arms in case of accident, 
and secondl}^, because of its situation and structure. It is composed 
of a soft, spongy tissue encased in a layer of compact bone, and is 
supported by the ribs and costal cartilages which act as a series of 
springs which absorb and modify shock. 

The sternum is usually ossified from six centers ; one each, for the 
manubrium and ensiform appendix, and four for the gladiolus. 




Fig. 537. — The sternum. M., manubrium; X., xyphoid cartilage; C, clavicle. The 
costal cartilages are numbered in order. 

Considerable variation occurs in the ossification of this bone. The 
lower sections of the gladiolus are not uncommonly ossified by two 
centers for each segment, and in anomalous instances lack of fusion 
between these lateral centers may result in a foramen or fissure in 
the lower part of the second portion of the sternum, even in adult 
life. This condition might be mistaken for a fracture if one is not 

453 



454 FRACTURES AND DISLOCATIONS 

acquainted Avitli the anomaly. The centers of ossification in the 
sternum make their appearance in order from above downward, the 
first being seen as early as the fifth foetal month, w^hile the center for 
the lower segment of the gladiolus is often not present until the 
second year. The center for the xyphoid cartilage may make its 
appearance anywhere between the second and eighteenth years. 
Fusion of the different segments of the sternum begins at about 
puberty in the low^er end of the gladiolus, and proceeds upward until 
the process is completed at about the twenty-fifth year. The 
xyphoid joins the gladiolus at about fort}'. The period at which 
fusion occurs between the manubrium and gladiolus is variable. 
They are usually continuous on the surface after middle life though 
the center of the articulation often remains soft even in the aged. 

The anterior mediastinum with its contents lies directly behind 
the sternum. 

The pectoralis major is attached to the anterior surface of the 
bone. The sternomastoid, sternothyroid and sternohyoid are at- 
tached to the upper end, w^hile the abdominal muscles are attached 
either directly or through their aponeuroses to the lower end of the 
bone. The diaphragm and triangularis sterni find attachments to 
the lower portions of the posterior surface. 

The anterior mediastinum with its contents lies directly behind the 
sternum. The heart lies directly behind the lower two-thirds of 
the sternum (excepting the xyphoid cartilage) . The pericardium is 
separated from the bone by the remains of the thymus gland above, 
and a small quantity of areolar tissue below\ The junction of the 
first and second pieces of the sternum may be felt as a transverse 
ridge on the bone, passing between the attachments of the second 
costal cartilages. 

Violent hyperextension, or overflexion of the spine, particularly 
the latter, may produce fracture of the sternum. The violent im- 
pact of the chin against the upper portion of the bone is said to 
have produced the condition. A blow on the chest ma}^, in rare 
instances, produce fracture. Gunshot injuries of this bone are not 
uncommonly seen even in civil life. 

In the aged, when ossification invades the costal cartilages, and the 
chest as a wdiole is more rigid, fracture is more easily produced ; but, 
on the other hand, the occupation and mode of life of those advanced 
in years expose less to trauma. A number of irregular types of 
fracture have been reported in which the condition was diagnosed 



FRACTURES OF THE STERNUM 455 

as eoinpound, eommiinited, multiple or longitudinal. These types 
of fracture, however, are extremely unusual in the sternum, the 
great majority being simple and transverse at, or near, the junction 
of the first and second pieces of the bone. The next most common 
deformity is one in which the upper fragment is displaced forward 
and slightly overlaps the lower piece. The common deformity con- 
sists in a displacement of the lower end of the upper fragment 
behind the lower fragment. The deformity is so characteristic and 
pronounced that a diagnosis can usually be made by inspection alone. 



Fig. 538. — Fracture of the sternum. Arrow indicates position of fracture which is 
in perfect reduction. Case of Dr. N. A. Thompson. 

Sometimes, however, a simple transverse fracture may exist without 
displacement, when the condition can only be recognized by palpa- 
tion, pressure being made first on one fragment and then on the 
other. The next most common site of fracture is at or near the 
junction of the first and second pieces of the gladiolus and resembles 
closely the more usual fracture occurring at Ludwig's angle. 

Symptoms. — The close relation existing between the sternum and 
thoracic viscera frequently results in complications involving these 
structures. It is seldom that we find fracture of the sternum un- 
accompanied by other injuries, so that the symptom-complex fre- 



456 FRACTURES AND DISLOCATIONS 

quently includes conditions such as fracture of the ribs, fracture of 
the spine, penetrating wounds of the chest, etc. In fracture of the 
sternum the patient usually assumes a hollow-chested attitude which 
is characteristic both in the erect and recumbent positions. Respira- 
tion is usually painful, rapid and superficial, resembling that seen 
in fracture of the ribs. 

Inspection and palpation of the chest usually reveals the charac- 
teristic deformity in the upper part of the sternum. When no 
deformity exists, crepitus is, as a rule, elicited without difficulty 
and in some instances may, by means of the stethoscope, be recog- 
nized with every respiration. 

Dislocations between the first and second portions of the sternum, 
in young persons, produce practically the same symptoms except 
that crepitus is more likely to be cartilaginous. The distinction 
between the two, however, is clinically of little importance. 
Cyanosis and dyspnoea may occur as the result of direct pressure 
from the displaced fragment. 

Treatment. — When deformity is absent from the first, or if reduc- 
tion has taken place spontaneously as sometimes occurs in normal 
respiration or in coughing, the only indication in the treatment is 
immobilization, which is most satisfactoril}^ accomplished by strap- 
ping the chest with adhesive plaster in a manner similar to that 
employed in fracture of the ribs. Direct pressure on either of the 
fragments may be obtained by a pad of gauze properly placed and 
held in position by adhesive plaster placed diagonally across the 
chest. A plaster cast including the chest and shoulders may be 
employed instead of the adhesive, although it does not accomplish 
the purposes of fixation any more satisfactorily. 

When deformity is present, it should be corrected before the chest 
is fixed. The reduction of displacement is accomplished in all 
instances by upward traction on the upper fragment, and downward 
traction on the lower. As a rule this is effected by posture, the 
traction and countertraction being applied indirectly through the 
muscles and other portions of the thorax. 

If the patient is placed on a table in the dorsal position with head 
and shoulders over the edge so that hyperextension of the spine is 
accomplished, reduction will usually follow without further manipu- 
lation of the fragments. Raising the arms above the head and direct 
pressure on the projecting fragment will facilitate correcting the 
deformity when simple hyperextension of the spine proves insuf- 



FRACTURES OF THE STERNUM 



457 



ficient. After the fragment has been brought into proper position 
the chest is fixed as previously described. 

Operative Treatment. — Various methods have been described for 
the open treatment of these deformities when simpler methods have 
failed to accomplish reduction, but it will be unnecessary to enter 
into the minutia? of these surgical procedures since they all are based 




Fig. 539. — Method of correcting deformity in overriding fracture of sternum. 




Fig. 540. — The method shown in Fig. 539 has been supplemented l)y di 
pressure on the inner ends of the clavicles vi^ith the finger tips. 



t upward 



on the same principles of traction, counter traction and manipula- 
tion after the fragments have been exposed by incision. Elevation 
has been accomplished by means of screws inserted into the depressed 
fragment. As a rule it will not be a difficult matter to pry the 
depressed portion of the sternum back into position with some strong 
instrument such as a periosteal elevator. The greatest care should 



458 FRACTURES AND DISLOCATIONS 

be exercised not to insert the instrument too far or in any way, 
either by cutting or laceration of the tissues, to open the pleural 
or pericardial sacs. In operating in this region we should bear in 
mind the course of the internal mammary artery one-half inch 
external to, and parallel with the lateral border of the sternum. If 
the origin of the pectoralis major interferes with the operative 
manipulations the fibres should be cut away so that the fragments 
are properly exposed. When reduction has been accomplished the 
incision is to be closed without drainage, and provision made in the 
fixation apparatus for the subsequent dressing of the wound during 
the after-treatment. 

After-Treatment. — Fixation of the chest should be maintained 
for from six to eight weeks following the accident and heavy work 
or violent exercise forbidden for another two or three weeks. Differ- 
ent types of steel braces and apparatus have been used with success 
to immobilize the chest and neck though they are seldom called for in 
a simple case. 

Prognosis. — The prognosis of simple, uncomplicated fracture of 
the sternum is good both as to life and function, but the frequency 
with which this fracture is associated with severe crushing injuries, 
such as fractures of the spine and complications of the thoracic 
viscera, renders the outlook variable, since the prognosis in these 
i:: stances is that of the complication rather than the fracture itself. 



CHAPTEE XXXIII. 

FRACTURES OF THE RIBS. 

Surgical Anatomy. — The surprising degree of trauma which the 
ribs are capable of withstanding is the result of their mobility and 
the natural spring which they possess. The first rib is the shortest, 
the seventh the longest. They are diagonally placed so that the 
posterior end of a given rib is at a considerably higher level than 
the anterior extremity. They increase in obliquity from above 
downward to the ninth rib, below which they become again more 
horizontal. The upper seven ribs are connected with the sternum 
through their own costal cartilages. The next three are attached 
through their cartilages to the ribs above, while the remaining two 
are floating. The first rib joins the sternum through its cartilage 
just below and behind the sterno-clavicular articulation. The sec- 
ond costal cartilage joins the sides of the sternum at Ludwig's 
angle. The lower border of the pectoralis major leads to the fifth 
rib, while the first visible digitation of the serratus magnus is 
attached to the sixth. The lower border of the tenth rib forms, 
from a surgical standpoint, the lower border of the thorax. The 
inferior margin of each rib is grooved on its deep aspect for the 
corresponding intercostal vessels. The sixth and seventh ribs are 
the ones most frequently fractured. The upper two ribs are more 
or less protected by the clavicle, while the heavy muscles of the back 
and the unattached condition of the eleventh and twelfth renders 
these lower ribs even more capable of withstanding trauma. 

The ribs may be broken by direct or indirect violence. The 
former occurs when the rib is fractured and driven inward at the 
point of impact ; the latter when breaking results from bending, as 
in forcible compression of the chest wall. The weakest point in 
the rib is just anterior to the angle, and it is here that fracture 
most often occurs when the result of indirect violence. The costal 
cartilages may be broken, a not uncommon site being at their junc- 
tion with the ribs. The close relations existing between the ribs 
and pleura account for the frequency of complications involving 

459 



460 



l^^RACTURES AND DISLOCATIONS 



this membrane and the underlying lung, especially in fractures 
produced by indirect violence. 

When a single rib is fractured there is little tendency toward 
displacement, since both ends are fixed, and the intercostal mus- 
cles maintain its relations with the ribs above and below. "When 
a number of consecutive ribs are fractured there is greater proba- 




Fractures of third, fourth, fifth and sixth ribs. 



bility of deformity, as is also the case when a single rib is broken 
in two or more places. 

Dislocation of the ribs may occur at either end, though their 
structure and the strength of their articulations render fracture 
by far the more common injury. Dislocation may occur at the 
vertebral ends of the ribs or at the mesial end of the first, second, 
eighth, ninth and tenth costal cartilages. 



FRACTURES OF THE RIBS 



461 



Symptoms. — Pain is a constant sj^mptom, being well localized in 
the region of the fracture. It is greatly increased by breathing, 
especially by deep inspiration. Coughing and sneezing render the 
suffering momentarily more intense. The patient usually stands 
or sits in an attitude characteristic of the condition, with the trunk 




Fig. 542. — Caving- in of chest with fracture of a number of ribs, the result of direct 
violence. Note the flattened condition of the chest on the patient's right side. Case 
seen with Dr. H. R. McGraw. 




Fig. 543. — Fracture and dibpluccuieut of a costal cartilage. 



bent slightly forward and toward the injured side. Respiration 
is shallow and rapid. The pectoral excursion on the injured side 
is usually less than that observed on the well side of tlie chest. 
Abnormal mobility is often present in the fractured rib near the 
site of the break. Crepitus may, or may not, be present accord- 



462 FRACTURES AND DISLOCATIONS 

ing to the relation of the serrated ends of the fragments. Swell- 
ing of the parts is slight, if present at all. Ecchymosis may make 
its appearance within the first twenty-four to forty-eight hours 
following the accident. The lung may be penetrated by one of 
the fractured ends. Bloody expectoration and subcutaneous 
emphysema are the most common indications of this complication. 
In pronounced cases the subcutaneous tissues of the chest, face, 
neck and arms may be extensively distended with air. Palpation 
gives a distinct sense of crepitation when air exists within the tis- 
sues. Traumatic pneumonia may follow if the lung is injured. 

Diagnosis. — The diagnosis is based on the symptoms just de- 
scribed, together with a careful and systematic examination of the 
chest. The ribs should be palpated in order, from above down- 
ward, for the purpose of recognizing crepitus and abnormal mo- 
bility. If pressure is made on a given rib, anteriorly (say the 
seventh), while the fingers of the opposite hand rest on the same 
rib in the posterior axillary line, the motion imparted to the rib, 
anteriorly, may be recognized by the opposite hand if the rib is 
intact between the points of palpation. If fracture is present, 
crepitus may be elicited in this manner, and dissolution of con- 
tinuity appreciated when present. As previously stated the ribs 
possess a certain amount of spring, wdiich quality should be tested 
w^hen examining for fracture. If the chest be gently compressed 
antero-posteriorly pain wdll be produced or increased at the seat of 
fracture, which is promptly recognized and indicated by the pa- 
tient. Crepitus, even with shallow respiration, may sometimes be 
determined by the stethoscope. Fractures of the posterior ex- 
tremities of the ribs are not infrequently extremely difficult to diag- 
nose because of their deep situation under the heavy muscles of 
the back. In such instances a radiogram will make the diagnosis 
possible. 

Treatment. — Fixation of the injured side of the chest is the first 
indication in fractures of the ribs. This is best accomplished by 
strapping the chest wdth zinc oxide adhesive plaster. The usual 
method of applying the adhesive straps or swathe to the back first, 
and then encircling the chest during expiration is contrary to the 
principles of surgical anatomy in this region. The anterior por- 
tion of the chest is the movable part, while the spinal portion is 
fixed. The strapping therefore should be done from before back- 
ward (see Fig. 544). AA^ien the injured side of the thorax is 



FRACTURES OF THE RIBS 



463 



fixed, relief from suffering is prompt and pronounced. The fact 
that the chest in respiration moves as a whole, renders it unneces- 
sary to always apply the strapping directly over the rib fractured. 
If the lower portion of the chest is fixed on the affected side, relief 
will follow, even though the fracture be situated in one of the 
upper ribs. In other words, if the lower four or five ribs are fixed 
on the aft'ected side motion in the entire half of the chest will be 
restricted. In severe fractures of the ribs, or in those presenting 
symptoms of pulmonary complications the strapping should not 
be applied too tightly, lest additional injury be done to the lung 
by forcing a displaced fragment or spicule into its substance. If 
suft'ering is not sufficiently relieved by strapping, the use of opiates 




Fig. 544. — Adhesive plaster strapping for fracture of the ribs. 

may be necessary during the first day or two following the accident. 

In fleshy persons, especially in women with pendulous breasts, 
fixation of the thorax is more difficult. The amount of subcu- 
taneous tissue renders the skin more mobile and cutaneous irrita- 
tion seems to be more readily produced, accordingly strapping is 
less satisfactory. In these cases a swathe snugly surrounding the 
lower chest will usually answer the purpose better than strapping. 

Subcutaneous emphysema does not ordinarily call for special 
measures, yet should the condition become severe it may be re- 
lieved by multiple incisions. 

After-Treatment,— The fixation dressing should be maintained 
for a period of about three weeks. In the milder cases in which 
a single rib is fractured, the patient may be up and about immedi- 



464 FRACTURES AND DISLOCATIONS 

ately following the injury. AYhen the condition is more severe, 
as when a number of ribs are fractured, or the lung penetrated, 
treatment in recumbency is demanded. If respiration is painful 
or difficult in the dorsal position the patient may find comfort in 
turning on his side, or the backrest may be used to raise him to a 
semi-sitting posture. It will often be necessary to tighten or re- 
apply the strapping if it becomes loosened, or if 'cutaneous irri- 
tation develops. For these reasons the patient should be kept 
under close observation especially during the early part of the 
after-treatment. A linen swathe may be used about the chest if, 
for any reason, strapping seems inadvisable. 

Prognosis. — Fractures of single ribs are almc-st invariably fol- 
lowed by complete restoration of function. Union with deformity 
is not likely to be followed by ill effects. The prognosis of severe 
crushing injuries, penetrations of the lung, traumatic pneumonia, 
etc., is that of the complication rather than of the fracture itself. 



CHAPTER XXXIV. 

FRACTURE-DISLOCATIONS OF THE SPINE. 

Considerable useless distinction has been made between "frac- 
ture" and ''dislocation" of the vertebrae. The use of the X-ray, 
of recent years, has demonstrated the fact that nearly all spinal 
fractures are complicated by at least some articular displacement, 
and that dislocations rarely occur without fracture of some por- 
tion of the vertebrge. This close association of the two conditions, 
therefore, renders the term ''fracture-dislocation" the most satis- 
factory and accurate, and it will be understood in the subsequent 
discussion of injuries to the spine that one condition rarely occurs 
without the other. Dislocations, uncomplicated by fracture, are 
sometimes seen in the cervical spine but almost never in the lower 
portions of the column. 

The importance of fractures and dislocations of the spinal column 
lies not so much in the bony injury sustained by the vertebrae, as 
in the damage which may be inflicted on the spinal cord contained 
within the spinal canal. In other words, the serious complica- 
tions which follow fracture of the spine are shown by the symp- 
toms of injury to the cord or spinal nerves rather than those of 
fracture of the spinal column. The diagnosis and treatment, 
therefore, come more properly under the head of neurology than 
of surgery. Since such is the case it will readily be seen that it 
is well for the surgeon, Avhen possible, to have the counsel and 
cooperation of an experienced neurologist in dealing with fracture- 
dislocations of the spine. 

Surgical Anatomy. — The character of the bony structure of the 
vertebrae is of importance in explaining the deformity which occurs 
in fracture-dislocations of the spine. The vertebral body is com- 
posed of a cancellous structure similar to that seen in the ends 
of the long bones. The surface is composed of a layer of com- 
pact tissue on which the strength of the body largely depends. 
In compression strains, little resistance remains after this bony 
capsule of compact tissue has been fractured; the internal can- 

465 



466 



FRACTURES AND DISLOCATIONS 



cellous tissue crushes readily and the body collapses. The verte- 
bral arches, though less in bulk, are composed of a heavy compact 
tissue with a comparatively small amount of enclosed cancellated 
structure. The result is that fracture of this portion of the verte- 
bra is more distinct and clean-cut in nature, with little or no loss 
of bone through crushing or impaction of cancellous tissue. The 
difference in the types of fracture occurring in these two portions 
of a vertebra may be likened to the difference existing between 
fracture taking place in the shaft, as compared to that seen in the 





Fig. 5J5. — Fracture of the bodies of the second, third and fourth cervical vertebra3 
with kyphotic deformity. 



expanded upper extremity of a long bone, such as the humerus. 

The usual strain producing fracture of the spine is that of 
hyperflexion, and the eft'ect upon the spinal column as a whole is 
similar to that occurring "when other materials are subjected to 
bending strain. The convex side of the rod or column is under 
tension, the concave side under compression, while the intermediate 
part is in a neutral condition until either the convex or concave 
side of the column breaks. With hyperflexion, therefore, the 
bodies of the vertebrae are under compression while the vertebral 



FRACTURE-DISLOCATIONS OF SPINE 



467 



arches aud connecting ligaments are subjected to tension. In most 
instances the compression strength of the bodies is less than the 
tension strength of the posterior spinal ligaments. The usual re- 
sult therefore, when the strain becomes greater than the spine can 
withstand, consists of a crushing of one or more of the vertebral 
bodies with kyphosis as a consequent deformity. 

The planes of the articular surfaces in the cervical spine are 
more nearly parallel with the upper and lower surfaces of the 
bodies than in other portions of the spine. This less firm inter- 




Fig. 546. — Fracture of body of second cervical vertebra with subluxation between 
bodies of second and third vertebrae. Fracture of second and third vertebrae near 
pedicles. 



locking in the cervical region accounts to some extent for the com- 
parative frequency of uncomplicated dislocations of the vertebrae 
in the neck. The upper portions of the spine normally carry less 
weight than the lower; hence the lighter structure in the cervical 
region. Accordingly the same degree of trauma will more surely 
produce fracture or dislocation in the neck than in other regions 
of the spine. As already explained the usual deformity is ky- 
photic ; yet we may see angular displacements in other directions, 
and the deformity may be overriding or rotary, as well as angular. 



468 



FRACTURES AND DISLOCATIONS 



In Pott's disease the vertebral body gives way under normal strain 
as a result of diseased bony tissue; in fracture of the spine, with 
kyphosis, the normal body collapses because of excessive strain; 
the deformity is similar in both instances. 

In the dorsal region, the articular surfaces change so they are 
more nearly- at right angles with the articular planes between the 
bodies. This results in greater strength and lessened mobility, so 
that it is almost impossible to slide one vertebra on another (be- 
yond ligamentous limits) without producing fracture. In the 




Fig. 547. — Dislocation between the first and second cervical vertebra? \s'ith forward 
displacement of the skull. 



lumbar region the articular surfaces are also nearly at right angles 
with the articulations between the bodies although they correspond 
more closely with the sagittal than with the coronal plane. 

The tips of the vertebral spines are subcutaneous and palpable 
from the sixth or seventh cervical to about the fourth sacral. The 
anterior surfaces of the bodies of the upper four cervical may be 
palpated through the pharynx; the lumbar bodies through the 
anterior abdominal wall, in thin persons; and the coccyx and 
lower end of the sacrum through the rectum. Otherwise the heavy 



FRACTURE-DISLOCATIONS OF SPINE 



469 




forniitv. 



Fig. 548. — Frartujp of the lower dorsal and upper lumbar vertebrae with lateral de- 



470 



FRACTURES AND DISLOCATIONS 



fasciae and erector spinae mass so conceal the deep portions of the 
vertebrae that it is impossible to accurately determine their con- 
dition and positions by palpation. 

The spinal cord lies within the spinal canal, extending down- 
ward from the foramen magnum to about the level of the inter- 
vertebral disc between the first and second lumbar vertebrae. The 
level of the lower end of the cord varies somewhat in different per- 
sons. It is said to extend to a relatively lower level in women than 




Fig. 549 



Figs. 549, 550 and 551. — Posterior view, sagittal section and anterior view of an 
old fracture of the spine. Note the constriction of the spinal canal and crushing of 
the Cauda equina opposite the third lumbar vertebra. 

in men, in short persons than in tall. This is explained by the 
growth of the individual. Early in foetal life the cord occupies 
the entire spinal canal but .the subsequent disproportion in growth 
between the spinal column and cord finds the conus terminal is on 
a level with the third lumbar vertebra at birth and later in life 
the cord terminates at the first or second lumbar according to the 
extent of longitudinal growth in the spinal column. 

In the early foetal arrangement the spinal nerves arise from the 



FRACTURE-DISLOCATIONS OF SPINE 



471 






deatli. 



Fig. 552. — X-ray plate of case shown in Figs. 549, 550 and 551. some weeks before 



472 FRACTURES AND DISLOCATIONS 

cord opposite the intervertebral foramina through which they 
emerge. The fact, however, that the spine grows faster than the 
cord lowers the level of the spinal exit for a given nerve, with 
relation to its spinal cord origin. All of the spinal nerves, there- 
fore, with the exception of the first two cervical, have a downward 




Fig. 553. — Fracture of the body of the fifth lumbar vertebra at the point indicated 
by arrow. 

intraspinal course of greater or less extent, varying with the level 
of the nerve. The lower the nerve, the longer its intraspinal 
course. 

The spinal dura or ''theca" forms a well, within the spinal canal 
extending from the foramen magnum to about the third sacral 
vertebra. The cord is suspended within this well and surrounded 



FRACTURE-DISLOCATIONS OF SPINE 473 

by cerebrospinal fluid in sucli a manner that injury by direct vio- 
lence is almost impossible if the spinal column remains intact. 
The denticulate ligament and spinal nerves steady the cord within 
the theca and serve to prevent its coming in contact with the walls 
of the canal. 

The tracts within the cord are composed of medullated aneurilem- 
matic axones, and when these fibres degenerate, following injury 
or disease, regeneration does not take place. Loss of function, 
therefore, is permanent. The spinal nerves,^ however, are both 
medullated and neurilemmatic and will regenerate under favorable 
conditions. This difference in structure and power of regeneration 
explains the invariable necessity for operative intervention to re- 
move pressure in injuries of the cauda equina. 

Symptoms. — The symptoms of fracture of the spine are, firstly, 
those of the bony lesion (the fracture itself) and secondly, those 
resulting from injury to the spinal cord or nerves. 

The symptoms of fracture of the spinal column are : 

1. Local pain and spasm. 

2. Abnormal mobility. 

3. Crepitus. 

4. Deformity. 

5. Loss of function. 

The symptoms following injury to the cord and spinal nerves are : 

6. Shock (and unconsciousness in cervical fracture). 

7. Changes in pulse, temperature and respiration. 

8. Motor disturbances. 

9. Sensory disturbances. 

10. Disturbances in reflexes. 

11. Trophic changes. 

Symptoms op Fracture of the Spinal Column. — 

1. Pain is usually present at the seat of fracture, and is similar 
in character to pain produced by fracture elsewhere.^ It is in- 
creased by motion and severe enough in some instances to produce 
syncope. 

2. Ahnormal mohility is usually present and can be recognized 
if the fracture has been at all severe. It is generally possible to 



1 Reflex pain is not here considered. 



474 



FRACTURES AND DISLOCATIONS 



flex the spine beyond normal limits, but the danger of producing 
or increasing injury to the spinal cord should preclude any and all 
unnecessary manipulations. 

3. Crepitus may or may not be present but any attempt to elicit 
same, simpl}^ for diagnostic purposes, is absolutely to be condemned 
on account of the possibility of injury to the spinal cord or nerves. 

4. Deformity varies with the region of the spine injured and the 
nature and degree of the fracture. It is almost invariably present. 
If the back be thoroughly inspected and carefully palpated the 
surgeon will, as a rule, experience little difficulty in recognizing 




Fig. 554 



Figs. 554 and 555. — Fracture of the spines of the third, fourth and fifth cervical 
vertebrae and of the bodies of the fifth and sixth. The thumb is depressed into the 
hollow caused by the displacement of the fractured spines. 

the gravity of the condition even though the details of the fracture 
cannot be ascertained without resorting to the use of the X-ray. 
The usual deformity consists of anterior angular displacement of 
that portion of the spine above the fracture, with resultant kyphosis. 
In unusual instances the loss of vertebral alignment may be rotarj^ 
In severe cases overriding as well as angular deformity of the 
spinal column may occur. Kyphosis is often sufficiently pro- 
nounced to be recognized by inspection alone. It is seldom that 
the important elements cannot be determined by palpation. Frac- 
ture of one or more of the spinous processes with loss of alignment 
in the tips of the spines may produce a slight deformity which can 



FRACTURE-DISLOCATIONS OF SPINE 



475 





Figs. 556 and 557. — Fracture of the spine in the lower dorsal region a few min- 
utes following the accident. Arrow in upper photograph indicates the visible irregu- 
larity in the spinous processes. In the lower plate (Fig. 557) the finger is pressed 
into the depression. 



476 FRACTURES AND DISLOCATIONS 

be recognized by palpation, if not by inspection alone. In isolated 
fracture of the spinous processes the deformity is slight and not 
accompanied by symptoms of fracture of the column itself, such 
as angulation of the spine, shock, motor and sensory disturbances, 
loss of function, etc. Fracture of the arches may be accompanied 
by symptoms of cord injury if the fragments have been displaced 
forward into the spinal canal. 

5. Loss of function is inevitable in fracture of the spinal column, 
and will be more or less complete according to the severity of the 
injury. Shock, pain, and cord injury may disable the patient, 
but aside from these conditions the mechanical disturbances pro- 
duced by the fracture are sufficient to prevent the patient from 
standing or sitting. Spasm of the muscles of the trunk, especially 
the erector spinge mass, will be present, and represents Nature's 
attempt at splinting the injured parts. Loss of function through 
isolated fracture of the spinous processes, is mainly the result of 
local pain, especially when the muscles attached to the involved 
spine are brought into action. Local swelling and ecchymosis are 
seldom pronounced, if they occur at all. The extravasated blood 
and fluids of inflammation are so bound down by the heavy dorsal 
fascia covering the erector spinge mass, that they seldom reach the 
surface. 

Symptoms Following Injury to the Cord and Spinal 
Nerves. — The symptoms following injury to the spinal cord or the 
nerves contained within the spinal canal vary with the complete- 
ness and region of the injury. The nature and degree of these 
symptoms are explained by reverting to the anatomy of the spinal 
cord and the distribution of the spinal nerves. Slight pressure 
on the spinal cord, such as produced by hemorrhage (and in some 
instances slight bony displacement), is prone to produce irritation 
of the spinal centers which, if allowed to continue, is not uncom- 
monly followed by a degeneration of the affected cells and their 
axones. Destruction of spinal cord tissue is invariably accom- 
panied by prompt loss of function in the destroyed cells, and 
interruption of impulses in the damaged white tissue of the cord. 
If the damage to these cells has been at all severe, degeneration 
ensues regardless of relief of pressure. If, however, pressure is 
not removed pressure myelitis is almost sure to follow, the degen- 
erative process will be more extensive, and adjoining cells and 
tracts will be involved, which were primarily unaffected at the 



FRACTURE-DISLOCATIONS OF SPINE 



477 




Fig. 558. — Fracture of the lower dorsal spine some eight years following the in- 
jury. The cord was partially crushed and paralysis of the lower extremities with loss 
of bladder and bowel control followed. Note the clironic sore in the sacral region and 
the cord about the hips supporting a urinal. 




Fig. 559. — A case of Charcot's spine showing the same type of kyphotic deformity 
as is sometimes seen in fractures of the lumbar spine. Paralysis of the lower extrem- 
ities and loss of sphincteric cpritrol due to pressure on the spinal nerves within the 
canal. 



478 FRACTURES AND DISLOCATIONS 

time of injury. There are none of the so-called silent areas within 
the cord similar to those existing in the brain, and hence lesions 
of the cord, either partial or complete, are always attended by dis- 
turbances in function. 

6. Shock, at least in a mild degree, accompanies all uncompli- 
cated fractures of the spine and is greatly augmented when the 
cord is injured. Unconsciousness, however, rarely occurs unless 
the injury is in the region of the upper four cervical vertebrae. 

7. Except in injuries of the upper cervical region pronounced. 
chmiges in temperature, respiration and pulse do not occur im- 
mediately following the accident. Shock may influence the tem- 
perature, pulse and respiration, but shock may occur in many con- 
ditions and is not characteristic of cord lesions. Later in the 
course of the case pressure myelitis, meningeal complications or 
degenerative processes within the cord may cause a rise of tem- 
perature, with alterations in the pulse and respiration. 

8. Motor disturbances at and below the seat of fracture, are the 
rule when the cord is injured and the character of these symptoms 
varies according to the nature, region and completeness of the 
lesion. In complete crushing of the cord paralysis will be found 
in the parts supplied by the damaged segments, and all the seg- 
ments below them will be thrown out of function. In partial in- 
jury to the cord the musculature supplied by the injured segments 
will show more or less complete flaccid paralysis, while the muscles 
supplied by lower segments will be spastic. The condition of the 
muscles will often be difficult to recognize immediately following 
the accident because of the accompanying shock and temporary 
loss of reflexes. 

The distribution of the thoracic nerves is simple and regular, 
and hence it is an easy matter to recognize the level of the spinal 
injury when the thoracic segments are involved. When, however, 
the injury is sustained by the cervical, lumbar or sacral segments 
it is necessary to understand the different plexus formations to 
appreciate the nerve distributions, and to be able to determine 
from the motor and sensory symptoms which spinal segments have 
been involved. In partial lesions of the cord the paralyses are 
often incomplete and asymmetrical. There may be weakness in 
certain muscles, with spasm, or complete loss of function in others. 
Irritative lesions commonly become paralytic as the case progresses. 
Paralysis of unstriped muscular tissue is seldom complete because 



FRACTURE-DISLOCATIONS OF SPINE 479 

of the additional nerve supply which it receives from the sympa- 
thetic system. Disturbances in the control of the bladder and 
bowel will be considered under injuries of the lumbar enlargement. 
The motor areas of the cord are more easily injured than the 
sensory, and hence in partial lesions motor paralysis is often more 
extensive and complete than are the sensory disturbances. The 
symptoms of cord injury following bony displacement are almost 
always paralytic from the first and are not progressive in nature. 
But on the other hand, hemorrhage within or about the cord is 
often accompanied by irritative symptoms, such as spasm or 
tremor, and the intensity of these symptoms usually increases both 
in degree and extent. Hematomyelia (hemorrhage into the sub- 
stance of the cord) and hematorrhachis (hemorrhage about the cord) 
are not uncommon complications of spinal cord injury. It is a 
peculiar fact that crushing injuries of the cord are frequently fol- 
lowed by hemorrhage into its substance a few segments above the 
site of the lesion. AVhen this secondary traumatic hematomyelia 
above the lesion occurs, it usually develops within the first few days. 
Hematorrhachis is more properly a complication than a sequel, 
since its onset is prompt following injury to the spinal plexus of 
veins at the seat of injury. In either of these conditions the symp- 
toms are, as a rule, progressive. The motor and sensory losses are 
not infrequently preceded by evidences of irritation in the spinal 
centers. In rare instances slight pressure upon the cord from 
bony displacement may produce symptoms simulating hemorrhage, 
provided the pressure is not sufficiently pronounced to produce 
immediate destruction of cord tissue. Under these conditions the 
symptoms may be irritative and occasionally slightly progressive. 

9. Sensory disturbances are common in cases of spinal cord in- 
jury, though in partial lesions they are usually less pronounced 
and extensive than are the motor symptoms. In complete trans- 
verse cord injuries anesthesia develops immediately in the areas 
supplied by the injured portion of the cord, and in addition the 
sensory function of all segments below the lesion is promptly, com- 
pletely and permanently lost. This area of anesthesia is soon 
followed by a girdle of hyperesthesia representing two or three 
spinal segments directly above the injured region of the cord. 
This area of hyperesthesia is the result of irritation of the spinal 
centers contained within the segments adjoining the lesion, and 
may be the only evidence of a hematomyelia which so commonly 



480 FRACTURES AND DISLOCATIONS 

develops in the cord tissue near the injury. Great suffering some- 
times occurs as the result of reflex shooting pains throughout the 
hyperesthetic area. This condition in the thoracic portion of the 
cord produces girdle pains ; in the lumbar enlargement, shooting 
pains in the lower extremities and genetalia ; while spinal irritation 
in the upper dorsal or lower cervical segments of the cord may 
produce pain in the upper extremities. Hyperesthesias following 
irritation of spinal centers will vary in degree and distribution ac- 
cording to the region and severity of the cord lesion. 

10. Disturbances in reflexes. — In complete cord lesions the re- 
flexes below the injury will be immediately, completely and perma- 
nently abolished. Shock, from any cause, may produce temporary 
loss of reflexes which return, however, as the patient recovers. 
Accordingly too much stress should not be laid on their absence 
immediately following the accident. In partial lesions the reflexes, 
dependent upon the damaged segments, will be lost or reduced, 
while those below the lesion are often absent immediately following 
the accident, though they return later and are often increased 
through lack of inhibition from the higher centers. When such 
is the case patellar and ankle clonus are present, together with 
Babinski's reflex, and other pathologic reflexes of the foot and 
ankle, indicating damage to the upper motor segment. The loss 
of reflex activity is often asymmetrical in partial lesions, and cor- 
responds more or less accurately to the distribution of motor and 
sensory losses. If the reflex of a given segment is increased 
through spinal irritation, spasm, tremor or hyperesthesia will prob- 
ably be present in the corresponding area. 

11. The trophic d'tstiirbances following injury to the cord are 
among the most serious and difficult to control of the complications 
with which we have to contend. Most prominent among them are 
the bed sores which develop where continued pressure is applied 
to subcutaneous bony prominences, especially in the region of the 
sacrum and heels. The sacral sores are often intractable, rapidly 
attaining such size and depth as to lay bare the lumbar and sacral 
vertebrae, and not infrequently a considerable part of the ossa 
innominata. When this type of sore develops the patient usually 
succumbs within a short time, either from exhaustion and a general 
septic condition or following involvement of the exposed spinal 
membranes. The musculature below the seat of injury atrophies 
until in extreme cases the outlines of the bones of the lower ex- 



FRACTURE-DISLOCATIONS OF SPINE 481 

tremities are apparent on inspection. Contractures are common, 
especially in the feet, which are often depressed and in a condition 
resembling that seen in hydrocephalus. The bladder changes are 
due partly to the effects of retention following paralysis, and 
partly to the disturbed trophic supply of the viscus. Infection of 
the bladder, with urinary decomposition, develops sooner or later 
in spite of the most assiduous care. This infection not infrequently 
ascends to the kidneys, ultimately producing death. 

The symptoms accompanying fracture-dislocations of the spine 
show such variation in different levels that for practical purposes 
we will consider the symptoms peculiar to the different regions. 

Fracture-dislocations of the cervical spine are often immedi- 
ately fatal, especially when the injury involves the upper four 
vertebrae. Dislocations uncomplicated by fracture are more com- 
mon here than in other portions of the spinal column (see "Anat- 
omy, ' ' page 465 ) . The usual deformity is kyphotic, though the dis- 
placement may, in unusual instances, be lateral, posterior, rotary 
or even overriding. Unilateral luxations are more common in the 
neck than in other portions of the spine, their usual seat being in 
the occipito-atlantal or in the atlo-axial articulations. If death 
does not follow the injury within a few hours motor and sensory 
disturbances develop in the regions supplied by the injured spinal 
segments and below the site of the lesion. Injuries at, or above, 
the fourth spinal segment destroy or interfere with the nerve sup- 
ply to the diaphragm, and the proximity of the important centers 
in the bulb, together with the close association between the pneu- 
mogastric and spinal-accessory nerves, renders fractures in this 
region especially dangerous. When death is not immediate pro- 
nounced variations are usually observed in the temperature, pulse 
and respiration. The temperature may rise to 105° or 106° or 
even higher, the pulse becoming rapid and arythmic. The more 
complete the loss of function in the phrenic, the more pronounced 
will be the action of the accessory muscles of respiration provided 
they are still capable of action. Fracture of the cervical region 
may involve the segments from which the nerves of the brachial 
are derived, and the muscles paralyzed in the upper extremity 
will vary according to the level of the lesion. When the lesion in- 
volves the upper portion of the brachial plexus the upper extremi- 
ties will be held in a characteristic position with the elbows flexed, 
and the upper arm abducted and rotated outward. Injury to the 



482 FRACTURES AND DLSLOCATIONS 

lower portion of the plexus produces a different attitude, with the 
arms not far from the side and the hands resting on the chest in 
pronation. The reason for these differences in attitude is ex- 
plained by the formation and distribution of the brachial plexus. 
In complete lesions of the cervical cord death almost invariably 
occurs within a few hours, if not at the time of the accident. If 
the patient survives the immediate effects of the injury the usual 
motor and sensory paralyses develop below the site of the injury, 
including loss of sphincteric control. If he lives a few weeks 
trophic disturbances make their appearances, the most important 
of which is the bed sore. 

Fracture-dislocations of the thoracic region are more constant 
in their type of deformity than are corresponding injuries in either 
the cervical or lumbar spines. Kyphosis with crushing of the 
body of the vertebra is the rule. Fractures of the upper thoracic 
region do not commonly influence motion or sensation of the upper 
extremities, though the usual symptoms develop below the lesion 
according to the severity of cord injury. Loss of sphincteric con- 
trol with sensory and motor disturbances of the legs and lower 
trunk are present. Diminished or lost peristalsis sometimes results 
in severe tympanites and fecal impaction, through interference 
with the nerve supply of the intestines. Any or all of the ab- 
dominal viscera may show diminished function. The thoracic por- 
tion of the spinal cord extends from the level of the sixth cervical 
interspace to the ninth thoracic vertebra, and hence fractures of 
the spine below this level involve the lumbar enlargement or the 
Cauda equina rather than the dorsal segments. 

Injury to the lumbar enlargement, situated opposite the lower 
three thoracic and first lumbar vertebra, gives rise to flaccid pa- 
ralyses of the lower extremities, varying in degree with the sever- 
ity of the lesion. The centers controlling the bladder, bowel and 
genitalia are all situated in this portion of the cord, and hence dis- 
turbances in function occur in these parts when this portion of 
the cord is injured. 

Injuries below the first lumbar vertebra may damage the nerves 
forming the cauda equina; the motor and sensory losses will vary 
according to the nerves injured. The reflexes in the lower ex- 
tremities will be lost if the nerves are crushed. Shock will be 
much less than that accompanying injury to the cord itself even 
w^hen all the nerves are crushed. 



FRACTURE-DISLOCATIONS OF SPINE 483 

Diagnosis. — The diagnosis of fracture of the spine and its com- 
plications, is based on the symptoms previously described. The 
alignment of the spine should be determined by inspection, and 
the tips of the spinous processes carefully palpated. Isolated frac- 
tures of the spines produce only local pain, abnormal mobility, 
and sometimes crepitus; the symptoms of fracture of the spine as 
a whole are absent. It is, as a rule, an easy matter to determine 
the presence of fracture in the spinal column, although an accu- 
rate appreciation of the details of the fracture is often only had 
by means of the X-ray or at autopsy. Unless the most careful 
examination is made in fractures without deformity the condition 
may be overlooked and subsequent displacement may produce in- 
jury to the cord which could have been prevented if proper fix- 
ation apparatus had been employed. The important element in 
fracture of the spine is that of cord injury, the degree and position 
of which determine the treatment. Complete transverse lesions 
produce immediate, total, permanent and symmetrical loss of mo- 
tion, sensation and reflexes below the lesion. Partial lesions are 
usually followed by irregular, incomplete and asymmetrical motor, 
sensory and reflex losses. The motor losses below the lesion are 
spastic, while the paralyses in the muscles supplied by the injured 
segments are flaccid. In complete lesions the motor losses, at and 
below the lesion, are all flaccid. In cord injuries, loss of motion 
in a single muscle, or group of muscles, never occurs. Such a 
condition means injury to one of the peripheral nerves rather 
than a spinal segment or nerve root. When a spinal nerve is 
crushed in one of the intervertebral foramina, the motor and 
sensory losses are confined to the distribution of that single nerve 
root. The loss of reflexes, accompanying shock and unconscious- 
ness, often prevents the surgeon from making an early diagnosis. 
The degenerative and inflammatory changes within the cord, fol- 
lowing pressure, may begin within a few hours of the injury, and 
hence the value of an early diagnosis is apparent. The symptoms 
of bony pressure are prompt in onset, and usually not progressive, 
while pressure due to hemorrhage produces symptoms which in- 
crease in severity as the blood escapes into or about the cord. 
Pressure myelitis, however, gives rise to symptoms which are prac- 
tically identical with those of hemorrhage, and in a given case it 
is not infrequently impossible to differentiate between the two. 
It is, also, extremely difficult in some instances to differentiate 



484 FRACTURES AND DISLOCATIONS 

between a partial lesion due to bony pressure and that due to 
hemorrhage. 

The difficulties of diagnoses in these cases are greatly increased 
by the manner in which shock and unconsciousness sometimes ob- 
scure the symptoms for a number of hours following the injury. 
Symptoms simulating complete lesions frequently" change within 
the first twenty-four hours, being replaced by the symptom-com- 
plex of a partial injury. The X-ray, especially in stereoscopic 
form, is sometimes of the greatest service in determining the ex- 
tent to which the lumen of the spinal canal has been encroached 
upon by bony displacement. The level of the cord lesion is de- 
termined by the level of the motor and sensory disturbances, par- 
ticularly the level of the hyperesthetic zone and the area of flaccid 
paralysis. 

Treatment. — The treatment of fractures of the spine is directed, 
firstly, towards the fixation of the injured portion of the column, 
and secondly, to the alleviation of complications and their symp- 
toms. With the exception of isolated fractures of the spinous or 
transverse processes fracture of the spinal column calls for a 
fixation in some form regardless of whether or not the cord has 
been injured. Fixation is most satisfactorily accomplished by 
means of a plaster cast, modified according to the region of the 
injury. In the cervical spine it should be so applied as to include 
the head, neck and shoulders, leaving the arms free. In the dorsal 
region, it will be necessary to include the chest and upper abdomen, 
together with the neck, if the fracture is high. When the lower 
dorsal or lumbar vertebra are fractured the cast should extend 
from below the armpits to the hips, including the crests of the 
ilia. In whatever region the cast is applied, the deformity should 
be previously corrected as perfectly as possible, and the patient's 
position maintained unchanged until the plaster has become suffi- 
ciently set to properly splint the parts. 

Fractures of the cervical spine may be held in reduction by the 
hands of an assistant while the cast is being applied. In the 
dorsal and lumbar regions, correction of the deformity is much 
more difficult because of the weight and bulk of the parts handled. 
Reduction in these portions of the column may be accomplished 
in a number of ways, any of which is satisfactory if properlj^ 
performed. The possibility of producing cord or nerve injury, or 
even death, while correcting the deformity should be constantly 



FRACTURE-DISLOCATIONS OF SPINE 485 

kept in mind during these procedures. All manipulations should 
be gradual, gentle, and guarded and the greatest care exercised in 
moving the patient to avoid strain or further displacement of the 
injured portions of the spine. 

If the patient is placed on two tables, face downward, and the 
tables so separated that the body sags downward between them, the 
deformity will not uncommonly be reduced without further ma- 
nipulation. Gentle pressure over the prominent spines may be 
necessary in addition to secure proper relations of the fragments. 
Two or three assistants will be necessary to securely hold the pa- 
tient at the shoulders and heels to prevent his slipping off the 
tables, and to maintain the proper degree of spinal curvature. 
In this position the surgeon may begin the application of the plas- 
ter bandages, the skin of the trunk having been previously pro- 
tected by means of a snug, soft woven shirt. Another method 
consists in suspending the patient in a hammock, and so regulating 
the tension at which the hammock is hung that the proper spinal 
curvature is obtained, and the deformity corrected. The Brad- 
ford-Lovett hammock frame is an excellent apparatus in the appli- 
cation of a cast of this kind. It matters little how the cast 
is applied provided the following essentials are observed: The 
deformity should be corrected ; the cast should be sufficiently heavy 
to withstand the subsequent strain; it should possess some non- 
irritating lining and should so secure the trunk that the spine is 
immobilized. A stomach pad consisting of two or three folded 
towels should be placed over the abdomen, before the plaster is 
applied and removed when the cast is completed. This allows 
room for comfortable respiration and eating during the after- 
treatment. It is essential that the cast remain exposed to the air 
(not covered with bed clothes) for twenty-four hours, or until the 
plaster has thoroughly set and dried. 

Immobilization of the spine may be accomplished in other ways 
besides the plaster cast, though probably not any more satisfactorily 
in the usual case. Steel braces, similar to those employed in the 
treatment of Pott's disease, may be used in fixing the spine. 

The water bed has been much used in the treatment of these 
cases, though the fixation of recumbency alone is by no means as 
efficient as that produced by the cast or brace. In the early treat- 
ment of fracture of the spine, extension and counter-extension may 
be employed by means of Buck's apparatus applied to both legs 



486 FRACTURES AND DISLOCATIONS 

with tlie foot of the bed raised. Sand bags about the body serve 
to steady the parts, and a small, hard pillow under the small of 
the back will maintain the proper dorsal curvature. The Bradford 
frame may be used to advantage when simple recumbency is the 
method of fixation. 

If the fracture is complicated by cord or nerve injury, the indi- 
cations to be met in the treatment are much more complex. In 
addition to fixation of the spine, the relief of symptoms resulting 
from the complication is demanded as far as may be possible. 
This may, or may not, require operation. When an absolute diag- 
nosis of complete crushing to the cord can be made, operation is 
contraindicated, since it can do no good. In partial lesions we 
should open the spinal canal at the seat of injury for the removal 
of such pressure as may be present. Fractures of the spine below 
the cord, with symptoms of injur}- to the cauda equina, call for 
operation. 

Operative Treatment. — The question of when to operate and 
w^hen to treat the patient expectantly has been the subject of much 
discussion. At the present time, however, it is commonly agreed 
by most surgeons that complete crushing injury to the cord should 
not be operated because of the hopelessness of the condition. The 
difficulty in determining when, and when not, to operate in a given 
case arises from the difficulty of an accurate diagnosis of the con- 
dition of the cord. Partial lesions to the cord and injuries to the 
Cauda equina demand operative intervention in almost all cases. 
The peculiarities of each individual case, however, must be consid- 
ered by themselves, and complicating conditions such as shock and 
injuries to other portions of the bod}^, especially the skull, neces- 
sarily modify the indications for operation and the best time for 
its performance. Compound fractures of the spine invariably call 
for surgical measures. The objects for which operation is per- 
formed, are: the correction of deformity, decompression of the 
cord, suture of nerves, and the treatment of the wound in com- 
pound cases. 

The permanency of the sensory and motor losses determines the 
completeness of the cord injury, but when operation is delayed 
for a few days to establish the diagnosis, the prognosis in partial 
lesions is rendered much worse by the development of pressure 
myelitis, and other degenerative processes Avithin the cord. For 
this reason some surgeons maintain that the spinal canal should 



FRACTURE-DISLOCATIONS OF SPINE 487 

be opened in practically all instances complicated by cord injury, 
for the sake of removing pressure in partial lesions which could 
not be otherwise differentiated from total crushes. If we follow 
this principle, we must, of necessity, submit many cases of com- 
plete crushing to operation for the sake of relieving pressure in 
instances in which the lesion proves to be only partial. The ques- 
tion might then be asked, and not without reason, ^'What harm 
has been done by operating upon complete lesions when they are 
hopeless from the first?" Spinal decompression is by no means 
as successful as might be wished, yet if only a moderate degree 
of improvement results the operation is justified. The state of 
the patient, even though he be confined to a wheel chair is much 
more tolerable than when he is completely bedridden and unable 
to help himself. 

The spinal canal ma}^ be opened by simple laminectomy, or by 
means of an osteoplastic resection. In performing a laminectomy, 
a median incision four or five inches long is made in the region 
of the injury. The muscles are separated from the spines and 
lamina^ on either side, preferably by blunt dissection. If hemor- 
rhage proves troublesome one side should be packed with gauze, 
while the other is being worked upon. It is next determined how 
many sets of spines and laminae are to be removed to properly 
expose the region of injury. The supra- and inter-spinus liga- 
ments and ligamentum subflavum are then divided below the low- 
est spine to be removed and above the uppermost pair of laminae 
to be included in 'the resection. Care should be taken not to 
introduce the scalpel too far in dividing the ligaments lest injury 
be inflicted on the contents of the neural canal. The laminae are 
next divided near their junction with the transverse processes by 
means of a saw, chisel or heavy bone cutting forceps, after which 
the osteo-ligamentous section is removed, exposing the dura. The 
theca is then opened by immediate incision, and the cord and its 
nerves examined. Inspection and palpation will disclose the na- 
ture and degree of pressure on the cord, together with the second- 
ary changes which may have occurred. Pressure may be relieved 
in some instances, by simply correcting the deformity in the column, 
or it may necessitate the chiseling away of bony prominences or 
the removal of fragments. Hemorrhage about the cord is readily 
recognized when the dura is exposed and opened. Hemorrhage 
into the substance of the cord gives a distended, swollen appear- 



488 FRACTURES AND DISLOCATIONS 

ance. It is probably wise to drain the contents of hematomyelia, 
though this procedure has not been performed sufficiently often to 
permit of trustworthy conclusions. The removal of spines and 
laminae leaves a deficiency in the spinal column, yet disturbances 
in function resulting from this loss are extremely rare. Lami- 
nectomy produces greater injury to the circulation than occurs 
in an osteoplastic resection, yet it has other advantages Avhich more 
than make up for the difference. When the normal anatomic re- 
lations are disturbed by fracture or dislocation, it is safer to expose 
the laminae before dividing them; there is less danger of injury 




Fig. 560. — Methods of wiring the processes together sometimes employed in operating 
on fractures of the spine. 

to the contents of the canal if the bony landmarks are exposed and 
the deformity accompanying the fracture fully appreciated. 

In opening the spinal canal by the osteoplastic method a 
U-shaped incision is made, the vertical arms of which are parallel 
to the spinous processes in the region of the injury. The soft tis- 
sues are divided by a deep incision, down to the laminse. The 
ligaments are then divided transversely between two vertebrae below 
the seat of the fracture as described in laminectomy. The laminae 
are then cut on either side near their junction with the pedicles, 
a sufficient number of arches being divided to turn four or five 
spines upward in the osteoplastic flap. When this operation is 
done in the dorsal region, where the spines are imbricated, it may 



FRACTURE-DISLOCATIONS OF SPINE 



489 



be necessary to remove the tip of the vertebral spine just above 
the base of the flap before the latter can be turned back. This is 
best accomplished through a short, median incision over the spine 
to be removed (see Fig. 561). After the deformity has been cor- 
rected, and the pressure, whether due to bone or blood, removed, 
the flap is sutured in position, with drainage in the lower angle. 
It is usually necessarj^ to apply a cast to maintain reduction. 

When injuries to the cord exist nothing can be done which will 
be followed by regeneration in the destroyed cells or tracts, yet 




Fig;. 561. — Lines indicating the incisions used in operations on the spine. A.-B., 
median incision employed in- laminectomy. The loop CD. is used in an osteoplastic 
flap. Tlie incision E.-F. is made to divide the spinous process above the flap so the 
flap may be turned back. 

deformity should be corrected and pressure removed to avoid the 
subsequent development of secondary complications. If spinal 
nerves are divided they call for suture, in addition to the removal 
of pressure. 

There is no established technique or mode of procedure in oper- 
ating upon fractures of the spine. The findings in a given case 
will point out the indications. The operations just described are 
for the purposes of relieving cord and nerve injuries, and have 
little to do, primarily, with the correction and fixation of the de- 
formity. Operation for these purposes alone is only rarely found 



490 FRACTURES AND DISLOCATIONS 

necessary. If an uncomplicated fracture of the spine exists, with 
pronounced tendency to the recurrence of deformity following re- 
duction, we may be justified in exposing the spines and laminae 
with a view to fixing them by means of wire as described by Hadra. 
The essentials of the method consist in securing sound spines above 
the injury to those below the seat of fracture, by means of silver 
wire (see Fig. 560). 

After-Treatment. — The after-treatment in fractures of the spine 
is directed firstly, to maintaining fixation of the fracture, and 
secondl}^, to the symptomatic treatment of disturbances resulting 
from cord or nerve injury. The apparatus used for fixing the 
spine whether cast, brace, extension or other apparatus, should be 
carefully inspected from day to day to avoid irritation of the soft 
parts which so often results in the development of sluggish sores. 
This applies to any form of fixation appliance employed in the 
treatment of fracture, but especially in complicated fractures of 
the spine when anesthesia and the loss of the protective pain sense, 
together with disturbed trophic supply favors the development of 
sores and extensive sloughs without the patient realizing his con- 
dition. The buttocks and heels require especial care to prevent 
the development of bed sores. A pneumatic ring may be used to 
relieve the sacral region from pressure, and pads of cotton may 
be placed under the tendo-achillis to prevent the heel resting on 
the bed. These parts, especially, should be bathed in alcohol twice 
daily if the slightest evidence of skin irritation is present. The 
perineal and gluteal regions should be kept scrupulously clean to 
prevent irritation from urine and feces. 

One of the most discouraging conditions with which we have to 
contend is that of cystitis which almost invariably develops fol- 
lowing the repeated use of the catheter. It is needless to say that 
the most strict aseptic precautions should be observed if cathe- 
terization is found necessary. It is advisable, when possible, to 
rely on the bladder's emptying itself, even when a moderate de- 
gree of urinary distention is present. Gentle massage of the dis- 
tended viscus will often" result in a fairly satisfactory evacuation 
of the bladder, and although this method is by no means ideal, yet 
it is far better to get along in this way than to resort to the 
catheter with its almost inevitable train of disastrous results fol- 
lowing infection of the genito-urinary tract. If the bladder be- 
comes infected during the after-treatment, it is often best to estab- 



FRACTURE-DISLOCATIONS OF SPINE 491 

lisli " permanent drainage to control the condition. Suprapubic 
cystotomy may be performed and a suction apparatus employed 
to keep the bladder empty. This is probably as satisfactory a 
method as any of dealing with infection of the bladder under these 
circumstances. "When analgesia is present in the hypogastric 
region, the operation may be performed without an anesthetic. 
The bladder should be washed at least once daily with a boric acid 
or potassium permanganate solution. Some surgeons prefer peri- 
neal drainage. Permanent catheterization has been employed with 
success, though the urethra will not tolerate the presence of a 
foreign bod}^ indefinitely. The intermittent use of hexamethylene- 
tetramine will be found of service in dealing with infection of the 
genito-urinary tract. 

Obstipation and fecak impaction sometimes accompany fracture 
of the spine, and must be dealt with by laxatives, enemata, mas- 
sage, and in some instances mechanical removal of the impacted 
material. 

The condition of some of these patients is so obviously hopeless 
that it is often wise to make them comfortable even though, in 
some respects, it may be at the expense of their physical welfare. 
Severe shooting pains in the hyperesthetic areas, when severe, call 
for the exhibition of opiates. 

Prognosis. — The outlook in uncomplicated fractures of the spine 
is good, especially when a fair reduction of the deformity has been 
accomplished. When, however, injuries to the spinal cord accom- 
pany the fracture, the prognosis is, at best, discouraging. There 
will be permanent loss of function, the degree varying with the 
extent of the injury, and the improvement which takes place in 
these cases is usually too trifling to be of real importance. Cases 
of partial injuries to the cord which survive the immediate effects 
of the accident, lead a life of invalidism varying from a few months 
to a few years. Cases of complete crushing of the cord seldom 
live more than a few months. Death usually follows as a result 
of some intercurrent condition, such as infection of the genito- 
urinary tract, meningitis, septic states, pneumonia, etc. The lower 
the injury in the spine, the better the prognosis. Operation is 
of no avail in complete crushing injuries, although it renders the 
prognosis much more favorable in partial lesions especially when 
done within a few hours of the injury. 



CHAPTER XXXV. 

FRACTURES AND DISLOCATIONS OF THE PELVIS. 

Surgical Anatomy. — The pelvis is originally made up of fifteen 
bones; three in either os innominatum, five in the sacrum and four 
in the coccyx. When ossification is complete we have but four, 
including the coccyx which is attached to the- lower end of the 
sacrum. The pelvis has fifty-five centers of ossification, some of 
which are of surgical importance. The os innominatum has three 
primary centers, one for each of the three bones entering into its 




Fig. 562. — The pelvis. S., Symphysis pubis; P., Body of pubis; A.R., Ascending 
ramus; I.-P.R., Ischio-pubic rami; I., Ischium; A. Acetabulum; A.S.I.S., Anterior- 
superior iliac spine; A. U.S., Anterior-inferior iliac spine. Lumbar and sacral verte- 
brae numbered in order. 

formation. The ilium, ischium and pubis meet in the acetabulum, 
and prior to the fusion of these three bones they are separated by 
a Y-shaped cartilage. A blow on the trochanter therefore, may 
break the os innominatum into its three anatomical parts, the in- 
jury resembling the epiphyseal separations seen elsewhere in the 
long bones. The three bones become united at about the seven- 
teenth year, after which this injury cannot take place. The entire 

492 



FRACTURES AND DISLOCATIONS OF PELVIS 493 

crest of tlie ilium may be separated as an epiphysis, or its anterior 
portion may be pulled away by muscular action prior to the twen- 
ty-fourth year, at which time it joins the rest of the ilium. The 
epiphysis of the anterior inferior iliac spine has been avulsed by 
the action of the straight head of the rectus femoris, and by trac- 
tion transmitted to it through the Y-ligament of Bigelow. The 
development of the sacrum is also of interest in this respect ; the 
lateral surfaces of the bone are ossified by plates which are in 
reality epiphyses. Fracture in this region will find the plane of 
least resistance, often following the epiphyseal cartilages rather 




Fig. 563. — Lateral view of pelvis. A.S.I.S., Anterior-superior iliac spine; AIIS.. 
Anterior-inferior_ iliac spine; GJI., Gluteus Maxiinus; G.Med.. Gluteus medius : Gluteus 
min., Gluteus minimus; A., Acetabulum; S.M., Semimembranosus; B., Biceps. 

than the articulation itself. Fracture of the incompletely ossified 
sacrum follows the cartilage rather than the bone. 

The ossa innominata transmit the weight of the body from the 
spine to the femora in the erect posture, or to the tubera ischiorum 
in the sitting position. The sacrum, together with that portion 
of the ossa innominata behind the acetabula, forms an arch for 
the transmission of weight to the femora; another arch with the 
tubera ischiorum as the base transmits the weight from the spine 
to the object on which the person sits. The anterior portion of 
the pelvis is composed of the pubes, and the rami which connect 
them above and below the thyroid foramina with the remainder 
of the pelvis. This part of the pelvis is composed of two counter- 



FRACTURES AND DISLOCATIONS 

„e.es for t.e support o. ^'^ ^::Z:^X^:'^^--^' 




,Mle the pulses and two *-f J^ Irt^IrrrcSL 
for the main arch ^^---^ f ]^^ ^^ j, ^„eh lighter than the pos- 
The anterior portion ^^ ^^%l^^l^^^ The main arches are very 
terior and more frequently fracturea 



FRACTURES AND DISLOCATIONS OF PELVIS 495 

strong and it not infrequently happens that the counter-arches are 
fractured by excessive strains which have been applied to the main 
arches, without however breaking the latter. When antero-pos- 
terior force is applied the anterior portion of the pelvis gives way 
first, and then, if the force continues to act, the lateral portions 
of the pelvis are forced apart and there is likely to be injury in 
the region of the sacro-iliac joints. Transverse violence breaks 
the counter-arches forcing them forward, after which the main 
arches give way and we have fracture of the lateral portions of 
the pelvis or in the region of the sacro-iliac synchondrosis. In the 
first instance fracture of the anterior portion is by direct violence, 
while the second is by indirect violence. The action of violence 
on the pelvis might be likened to the mechanism of fracture of the 
skull, which results in fracture ''by bending" and fracture ''by 
bursting." « Isolated fracture of the posterior portion of the pelvis 
only occurs in the presence of well localized and severe trauma. 
Numerous muscles are attached to the surface of the pelvis, both 
internally and externally, and these muscles each have a displacing 
tendency when fracture is present. Their origins and insertions 
should be understood in order that we may appreciate their influ- 
ence on deformity. 

To the crest of the ilium we have the erector spinse, the latissimus 
dorsi, quadratus lumborum, external oblique, internal oblique and 
transversus abdominalis, tensor vaginae femoris and sartorius. 
These muscles, with the exception of the last two, pull in an up- 
ward, or upward and inward direction, while the last two pull 
downward toward the thigh. The external surface of the ilium 
affords attachment to the three gluteal muscles, while the inner 
surface, above the brim of the true pelvis, is taken up by the 
origin of the iliacus. The pubis affords attachment to the con- 
joined tendon of the internal oblique and transversalis, the tendon 
of the external oblique, rectus and pyramidalis. All the muscles 
of this group pull upward, or upward and outward. The anterior 
surface of the pubis and the ischiopubic rami afford attachment 
to the adductor muscles ; the tuber ischii to the semimembranosus, 
semitendinosus and the biceps, all of which have a downward pull. 
When the fragment is free the tendency is toward displacement in 
the line of pull of the muscle attached. The vascular and nervous 
structures passing under Poupart's ligament lie close to the ascend- 
ing ramus of the pubis and may be injured by displaced fragments. 



496 FRACTURES AND DISLOCATIONS 

"We have the internal piidic artery running on the inner surface 
of the ischiopubic rami where it may be injured when this portion 
of the pelvis is fractured. The structures passing through the 
greater and lesser sciatic foramina are also to be considered in 
fracture of the posterior portion of the pelvis. 

The bladder lies behind the pubes and is more or less attached 
to the bones by fibrous tissue ; it may be injured by compression 
when the viscus is full, by the penetration of fragments or by the 
pull of the connective tissue w^hen portions of the bone are dis- 
placed. The two layers of the triangular ligament, composed of 
heavy fibrous tissue, are firmly attached to the ischiopubic rami 
which form the subpubic arch. When this arch -is fractured the 
ligament is usually torn and since the urethra passes through the 
ligament it may also suffer injury. The rectum is situated in the 
posterior portion of the pelvis, follows the curve of the anterior 
surface of the sacrum and coccyx, and in this protected position 
is rarely injured. The nerves passing through the sacrum and 
in close relation to the coccyx may be injured wiien this region of 
the pelvis is fractured. 

Etiology. — Fracture of the pelvis is usually the result of great 
violence such as occurs when the patient is caught between two 
railroad cars or crushed beneath falling rock in mine accidents. 
Falls from heights may produce the condition, the force often being 
transmitted through the femora or tubera ischiorum. Fracture of 
the pelvis is comparatively a rare accident, constituting about one- 
half percent of all fractures. The flaring ilia are more frequently 
fractured than is the true pelvis because of their lighter structure 
and more exposed positions. 

Classification and Pathology. — The pelvis is a complex structure 
both in its bony parts and its relation to viscera. The different 
portions of the pelvis should be studied individually, and then the 
pelvis as a whole is to be considered with reference to its various 
functions. Like the skull, the most important feature of fracture 
of the pelvis consists of the injury which may be sustained by 
adjacent soft tissues, in other Avords the complications occurring 
in fracture of the pelvis are far more serious than the fracture 
itself. 

Fracture of the pelvis may be divided clinically into complicated 
and uncomplicated cases. Uncomplicated fracture commonly oc- 
curs in isolated fracture of some one of the three bones forming 



FRACTURES AND DISLOCATIONS OF PELVIS 497 

the OS innominatum while the complicated type is most commonly 
seen when the pelvic girdle is fractured. 

Uncomplicated fracture most frequently occurs in : 

1. The upper expanded portion of the ilium. 

2. The rim of the acetabulum. 

3. The tuberosity of the ischium. 

4. The coccyx and tip of the sacrum. 

The complicated type is represented by: 

1. Separation of the symphysis pubis. 

2. Fracture of the pubic and ischiopubic rami. 

3. Vertical fracture of the lateral portions in the region of 

the acetabulum. 

4. Separation of the sacro-iliac joints. 

5. Transverse fracture of the sacrum. 

Considerable useless distinction has been made between fracture 
and dislocation of the pelvis. Probably the only real dislocation 
occurring in the pelvis is that of the coccyx. The so-called dislo- 
cations described as having taken place in the sacro-iliac synchon- 
drosis are at most only subluxations, usually complicated by frac- 
ture in the immediate neighborhood of the joint. In most of the 
reported cases of sacro-iliac dislocation fracture has been recog- 
nized as a complication and in other instances the report would 
indicate that the presence of fracture had not been properly ex- 
cluded by X-ray examination. Separation of the symphysis may 
be considered as a dislocation though it is probably more in ac- 
cordance with the pathological facts to place it under the heading 
of fractures. 

Symptoms. — The symptoms of fracture of the pelvis will vary 
according to the region of the injury and the complications present. 
Isolated fracture of a small portion of the pelvis such as the 
anterior superior iliac spine will not, as a rule, give rise to more 
than local symptoms. There will be more or less localized pain 
which is increased when the patient moves about. On examination 
we find abnormal mobility, crepitus, tenderness, swelling, etc. 
But, on the other hand, when the pelvic girdle is fractured and 
complications are present, we have a very different clinical picture. 
Shock is a prominent symptom as evidenced by pallor, cold clammy 
skin, weak rapid pulse, etc. Collapse and unconsciousness may 



498 FRACTURES AND DISLOCATIONS 

supervene in pronounced cases. If conscious the patient suffers 
intense pain and deformity of the true pelvis is present to a greater 
or less degree. It is often possible to elicit abnormal mobility 
and crepitus upon examination though the surgeon should exer- 
cise the greatest care to avoid further injury to the viscera by 
manipulation. Inability to walk may be due to pain, shock and 
visceral injury or it may be the result of mechanical disturbance 
in the weight-carrying function of the pelvis. If that portion of 
the pelvis bearing the acetabulum is displaced upward there will 
be shortening in the lower extremity of the same side. To these 
symptoms will be added those peculiar to the complications present. 

Of the uncomplicated fractures of the pelvis, i&olated fracture 
of the upper expanded portion of the ilium is the most common, 
while fracture of the anterior portion of the pelvic ring is the most 
frequent representative of the complicated type. 

The symptoms occurring in the different types of uncomplicated 
fracture of the pelvis are as follows : 

1. Ft^aciure of the upper expanded portion of the ilium will be 
accompanied by pain in the region of the injury, tenderness and 
often swelling. Ecchymosis frequently develops after the first 
twelve or twenty-four hours. Pain will be increased by any motion 
which calls into activity the muscles attached to the fragment or 
fragments. When the course of the fracture is horizontal the 
crest may show marked upward displacement. The line of frac- 
ture will frequently be found running downward and forward from 
the middle of the crest, or less commonly downward and backward 
from the same point. The fracture is usually due to direct violence 
and accordingly bruises or abrasions are frequently seen in the 
skin over the region of injury. In rare instances the intestines 
lying in the hollow of the ilium may suffer injury, producing symp- 
toms of shock and peritonitis. When the fracture is confined to the 
region of the anterior superior iliac spine the fragment may be dis- 
placed forward and outward due to the combined actions of the 
abdominal muscles, sartorius and tensor vaginse femoris. When 
the fragment includes only a small part of the crest and only a small 
portion of the abdominal muscles are attached, the action of the 
thigh muscles just mentioned will be practically unopposed, resulting 
in downward displacement. 

Crepitus is usually present but is by no means constant, since 
the fragments are not always in contact. Relaxation of the muscles 



FRACTURES AND DISLOCATIONS OF PELVIS 



499 



of the abdomen and thigh will render palpation of the fragments 
easier and often enable the surgeon to elicit crepitus which would 
otherwise be absent. This may be accomplished by placing pillows 
beneath the patient's shoulders and flexing the thighs. 




Fig. 565. 




Fig. 566. 

Figs. 565 and 566. — Fracture of the left ilium with tearing away of the abdominal 
muscles from the iliac crest. Note the change in outline with the patient in the 
lateral recumbent position. (Atrophy of right thigh result of old amputation of right 
leg.) 



2. Fracture of the rim of the acetabulum does not occur except 
as a complication of displacements of the head of the femur. The 
upper posterior part of the rim is the portion of the acetabular cir- 



500 FRACTURES AND DISLOCATIONS 

cumference most frequently detached by the head of the femur as 
it leaves the cavity. Fracture of the rim of the acetabulum with 
displacement of the femoral head results in shortening of the limb 
of the affected side though the position assumed is not necessarily 
characteristic of dorsal dislocation of the hip. Slight manipulation 
of the thigh with traction is usually sufficient to bring the head of 
the femur back into place though the deformity recurs either imme- 
diately or within a few hours following reduction. It differs from 
dislocation of the hip in the ease with which reduction is accom- 
plished and the tendency to recurrence of deformity. The condition 
however closely resembles fracture of the neck of the femur, having 
frequently been mistaken for it. 

In fracture of the neck of the femur the arc described by the 
trochanter when the thigh is rotated is of shorter radius than normal. 
In fracture of the rim of the acetabulum this arc is normal as may 
be demonstrated by comparison with the opposite side. This differ- 
ence, however, is often slight and difficult to determine, so that the 
use of the X-ray will frequently be necessary to determine the 
pathology of the case. The fragment usually follows the head when 
the latter is returned to the acetabulum, and crepitus will be pro- 
duced as the fractured surfaces pass each other. This crepitus may 
be as pronounced as in fracture of the hip, or it may be exceedingly 
indistinct according to the position of the fragment. 

3. Fracture of the tiiherosity of the ischium is an exceedingly 
rare condition being the result of severe localized trauma. The 
condition is therefore likely to be accompanied by wounds of the 
soft parts which may reach to the bone, rendering the fracture com- 
pound. Abnormal mobility and crepitus may be elicited by palpa- 
tion through the rectum or vagina, while the opposite hand gives 
counter-pressure through the gluteal muscles. Local pain, tender- 
ness, etc., will be present. 

4. The coccyx may he fractured or dislocated by direct violence 
acting either from without or within. It most often follows falls 
on the buttocks and may be displaced forward, laterally or back- 
ward, the latter being the result of forces acting from within the 
pelvis, such as the descending head of the child. The distinction 
between fracture and dislocation of this bone has been the subject of 
much discussion between certain writers, but for practically clinical 
purposes it matters little since the symptoms and treatment are 
identical. The pain in fracture or dislocation of the coccyx may be 



FRACTURES AND DISLOCATIONS OF PELVIS 501 

surprisiugiy severe considering the actual damage done. Before 
reduction is accomplished the patient usually presents the symptoms 
of agonizing pain which radiates up the back and down the dorsal 
aspect of the thighs from the seat of injury. Even after the suffer- 
ing has been relieved by correcting the displacement it will be many 
days before the patient can move about with any degree of comfort. 
The fracture may take place through the lower end of the sacrum so 




Fig. 567. — Lateral dislocation of the coccyx. The arrows point to the coccyx 
which has been outlined to accentuate its position. The lower arrow passes through 
the symphysis pubis. 

that a portion of this bone is displaced with the coccyx. The higher 
the fracture in the sacrum the greater the likelihood of injury to the 
nerves contained within the sacral canal and emerging through the 
sacral foramina. Injury to these nerves may produce pain, numb- 
ness, loss of function, etc., throughout the region of their distribu- 
tion, and in severe cases to trophic disturbances with sores or sloughs 
in the skin covering the coccyx and lower end of the sacrum. The 
coccyx and sacrum become one bone in the aged so that fracture of 



502 FRACTURES AND DISLOCATIONS 

the tip of the sacrum is more likely to occur after the articulation 
has been obliterated. 

The usual displacement of the coccyx is angular and forward so 
that the tip of the bone may be felt pointing forward when the 
examining finger is introduced into the rectum. This displacement 
encroaches upon the cavity of the rectum, rendering bowel move- 
ments extremely painful. The lateral and posterior displacements, 
which are extremely rare, do not tend to recur following reduction ; 
the anterior displacement however does tend to recur as a result 
of the action of the attached muscles. Lateral displacements may 
be palpated through the rectum; posterior displacements will be 
accompanied by an abnormal prominence in the lower part of the 
gluteal cleft. 

The symptoms occurring in complicated fracture of the pelvis 
will depend on the region of the pelvis injured, together with the 
nature and extent of the injury sustained by the soft parts in the 
region of the fracture. AYhen any portion of the pelvic girdle is 
fractured numerous complications may exist so that it will be best 
to consider the bone injuries first in the order previously set down, 
after which the complications will be taken up. 

The mechanism and pathology of fracture of the pelvic girdle 
are of secondary importance when compared to the complications 
commonly found accompanying this condition. 

1. Separation of the symphysis puhis may be the result of 
indirect violence forcing the ossa innominata apart, due to the 
overaction of the adductor group of muscles while the thighs are 
in abduction, or to the spreading action of the foetus as it descends 
through the parturient canal. The separation of the pubes may 
be felt and in man}^ instances seen. Separation of over one and a 
half inches is, as a rule, accompanied by rupture of the anterior 
sacro-iliac ligaments or fracture in some other portion of the 
pelvic ring. 

With separation of the symphysis the patient suffers considerable 
pain and the weight bearing function of the pelvis is interfered 
with as a result of the dissolution of the counter-arches. Rupture 
of the ligaments and loosening of one of the sacro-iliac joints will 
allow one os innominatum to be displaced, usually upward. 
Symphyseal separation may be associated with fracture of the 
pelvis or with loosening of one or both sacro-iliac joints. One 
pubic bone may be displaced behind the other and wlien such is 



FRACTURES AND DISLOCATIONS OF PELVIS 503 

the case it is usually very difficult to reduce the deformity. The 
common complication is rupture of the urethra or bladder, the 
sj'mptoms of which will be described later. 

2. Fracture of the anterior portion of the pelvic ring occurs 
more frequently than any of the other fractures in this group. 
The details of the lines of fractures vary greatly. Both rami of the 
pubis are usually fractured, the upper one anterior to the ilio- 
pectineal eminence and the lower near the junction of the descend- 
ing pubic with the ischial ramus. The condition is not infre- 
quently bilateral. Deformity is usually present and can be de- 
tected by palpation. The condition may be the result of violence 
applied to the pelvis in the antero-posterior direction or it may be 
due to lateral squeezing. Fractures in the lateral or posterior 
portions of the pelvic ring are common as complications, and are 
seen in instances in which the causative trauma continues to act 
after the anterior portion has been fractured. The patient is 
unable to walk, pain is severe, and shock often pronounced, 
especially in the presence of visceral complications. Rupture of 
the bladder and injury to the urethra are common as complica- 
tions (see page 509). 

3. Fracture of the lateral portions of the pelvis in the region of 
the acetabulum occurs in conjunction with fracture of the anterior 
portion of the ring as previously explained, and also as a result of 
trauma transmitted through the head and neck of the femur. The 
first named type of fracture is more or less vertical, passing from 
the crest of the ilium to the great sacro-sciatic foramen. The line 
of fracture frequently branches in its upper end. It may pass 
into or cross the sacro-iliac joint involving the sacrum: in other 
instances it comes out below the anterior inferior iliac spine. 
When it crosses the sacro-iliac joint it may follow more or less 
closely the line of the articulation, or it may follow the sacral foram- 
ina separating the lateral mass of the sacrum from the rest of 
the bone. The directions which the lines of fracture may take in 
the lateral portions of the pelvis are very variable and accordingly 
two cases will seldom show the same deformity. The fact that the 
femur articulates with this portion of the pelvis often gives rise 
to symptoms of importance. The lower extremity of the affected 
side usually lies helpless and is shorter than normal because of the 
displacement of the acetabulum. The muscles of the thigh are in 
spasm and any attempt at passive motion is seriously objected to 



504 FRACTURES AND DISLOCATIONS 

by tlie patient. Abnormal mobility and crepitus can, as a rule, be 
elicited with ease by direct palpation or manipulation of the thigh, 
and the pelvic deformity is often plainly visible. Injury to the 
acetabulum and adjoining pelvis resulting from trauma transmitted 
through the femur is rare, because when violence is applied to the 
trochanter the neck of the femur is much more liable to fracture 
than is the pelvis. The condition, however, does occasionally occur 
and a variety of fractures may result when the pelvis is injured 
in this manner: the acetabulum may be "broken out," so to speak, 
of the rest of the pelvis with three lines of fracture, one from a 
point below the antero-inferior spine to the great sacro-sciatic 
notch, the second across the ascending ramus of the pubis and the 
third across the body of the ischium below the acetabulum; 
another result is that the violence applied to the acetabulum pro- 
duces radiating fractures which, following the lines of least resist- 
ance, reach the sacro-sciatic notch, thyroid foramen and rim of the 
pelvis; in addition we may have injury of the bone at the bottom 
of the acetabular cavity without fracture of adjoining portions of 
the pelvis. A rare condition is sometimes seen in which the head of 
the femur is driven through the bottom of the acetabulum into the 
pelvic cavity. The symptoms of deformity and disturbance in 
function will vary with the pathology of the condition. When the 
acetabulum is fractured there is likely to be shortening of the 
lower extremity, abnormal mobility of the upper end of the femur 
and crepitus when the thigh is manipulated. When the head of 
the femur is driven through the acetabulum there will be abnormal 
fixation of the upper end of the femur, mesial displacement of the 
trochanter as palpated externally, and the patient will be able to 
bear the weight of the body on the limb of the affected side since 
the ring of the pelvis is not fractured and the weight is trans- 
mitted to the neck of the femur instead of to the head. The shock 
and pain, however, will usually be sufficient to prevent the patient 
attempting anything in the way of walking. Fracture of the 
pelvis by lateral compression is usually preceded by fracture of 
the ''tie arches" composing the anterior part of the ring, so that 
the symptoms of fracture of both these portions of the pelvis will 
be present at the same time. 

4. Separation of the sacro-iliac synchondrosis, as an isolated 
injury, is an extremely rare condition. It occurs sometimes in 
conjunction with fracture of the anterior portion of the pelvic 



FRACTURES AND DISLOCATIONS OF PELVIS 505 

ring or separation of the symphysis pubis. Inward displacement 
of the lateral portions of the pelvis, such as occurs in transverse 
crushes, may result in rupture of the posterior ligaments behind 
the articular surfaces. Spreading of the pelvis throws the strain 
on the anterior sacro-iliac ligaments, which rupture, allowing the 
anterior aspect of the joint to gape. The strength of these liga- 
ments, however, is so great that fracture in the adjoining bone is 
more frequently produced than rupture of the ligament itself. 
Displacement in one or both sacro-iliac joints, or separation of all 
three pelvic articulations is known to have taken place, but such 
conditions are very rare. Laxity or rupture of the ligaments of 
the sacro-iliac joints will allow an upward and outward displace- 
ment of the ilium if the patient attempts to sit or stand. Disturb- 
ances in function following injury to the pelvic articulations will 
give rise to symptoms similar to those occurring in fracture of the 
same region. The sacro-iliac joints are not infrequently subject 
to sprains in falls and blows on the pelvis, and although the con- 
dition is by no means a dislocation, it deserves mention. There is 
more or less pain in the joint when the patient moves about, and 
pressure on the anterior superior spines produces pain in the region 
of the injury. The condition is usually not serious, being followed 
by prompt recovery with rest in bed for a few days. 

5. Transverse fracture of the sacrum is the result of severe local- 
ized trauma and is fortunately a rare condition. A small portion 
of the sacrum may be displaced with the coccyx but this condition 
is described under fracture of the coccyx. The fragment in trans- 
verse fracture of the sacrum is usually displaced forward, project- 
ing into the cavity of the pelvis and is commonly accompanied by 
injury to the rectum and the nerves contained within the sacral 
canal. The displacement is easily detected by palpation. Severe 
pain, radiating up the back and down the thighs, may be present. 
Shock is often pronounced. Paralysis of the bladder and rectum, 
due to injury of the nerves supplying these structures as they pass 
through the sacrum, is not uncommon. Paralysis of the lower leg 
type has been noted in some cases. The displacement is produced 
by the original trauma and the action of the attached muscles. 
The deformity usually recurs promptly following reduction. 

Diagnosis. — "When fracture of the pelvis is suspected the exam- 
ination should be conducted systematically in order that the full 
extent of the injury may be recognized. Moreover the examination 



506 FRACTURES AND DISLOCATIONS 

should not be considered complete as soon as we find one line of 
fracture, since multiple fracture and visceral complications are 
common. The patient - should be placed in a position which is 
accessible and convenient for the surgeon, preferably an operating 
table, and unless there are special contraindications it is advisable 
to administer a short anesthetic. The pelvic girdle is covered with 
a number of muscles and many of its parts are deeply situated, yet 
by proper palpation fracture and articular displacements can, as a 
rule, be determined without difficulty. By inspection alone it is 
often possible to detect asymmetry of the two sides of the pelvis, 
raising of one of the ossa innominata, or the median depression of 
symphyseal separation. The shortening and helpless attitude in 
which the lower extremity may lie is indicative of fracture of the 
femur or pelvis. Palpation will usually elicit crepitus and ab- 
normal mobility in the presence of fracture or separation. With 
the patient in the dorsal position and the pelvis solidly supported, 
backward pressure is made with the palms of the hands on the 
antero-superior iliac spines, then the iliac crests are crowded 
together and finally antero-posterior pressure is exerted with one 
hand over the symphysis and the other on the sacrum. Pressure 
in these directions will usually elicit mobility and crepitus if the 
fracture has passed through the pelvic girdle. Due care should 
be exercised to avoid further injury to the viscera in manipulating 
the parts since the examination may thus inflict more serious 
injury. The pubes and their ascending rami are near the surface 
and their outline may be followed throughout. The mesial borders 
of the ischio-pubic rami may be palpated at the lateral boundaries 
cf the perineum with the thighs abducted. The anterior superior 
iliac spines are subcutaneous and the iliac crests may be palpated 
throughout their extent, terminating posteriorly in the postero- 
superior iliac spines. The tuberosity of the ischium may be 
palpated with the fingertips of one hand resting in the lower part 
of the gluteal cleft while the opposite hand makes counter-pressure 
through the buttock. It may also be palpated through the rectum 
or vagina. The spines of the sacrum may be palpated throughout 
but the remainder of the posterior surface of the bone is obscured 
to touch by the heavy fascia covering the lower end of the erector 
spinge mass. If the finger be passed into the rectum and the thumb 
opposed posteriorly the coccyx may be thoroughly palpated, and 
the presence of abnormal mobility and crepitus determined when 



FRACTURES AND DISLOCATIONS OF PELVIS 507 

present. The presence of fracture is, as a rule, easily recognized 
by palpation as above described, but it is often impossible to deter- 
mine the details without employing the X-ray. 

Treatment. — The treatment of fracture of the pelvis aside from 
the complications is usually a simple matter. If the deformity is 
not great immobilization and rest in bed will be all that is required. 
In fracture of the crest of the ilium a body swathe may be used or 
adhesive straps may be employed to steady the fragment. Too 
much pressure should be avoided, as it may displace the fragment 
inward, thus increasing the deformity. Rest in bed is necessary 
and the patient should be warned against undue use of the 
abdominal muscles. The bowels should be kept soft to avoid 
straining at stool. IModerate deformity does not mean impairment 
of function and seldom requires special measures for its correction. 
A flattened hip in a young woman, however, is often considered a 
serious matter and we may be called upon to secure the fragment 
by operation for the correction of deformity. Fracture of the rim 
of the acetabulum is to be treated similarly to fracture of the hip 
and will be considered with the treatment of fractures of the upper 
end of the femur. Fracture of the tuberosity of the ischium rarely 
shows great displacement and recovery with moderate deformity is 
followed by good function. Rest in bed and a pneumatic ring to 
relieve the region of fracture from pressure will constitute the 
essentials of treatment. If the tuberosity, however, shows enough 
inward displacement to encroach on the transverse diameter of the 
birth canal in a woman of the child-bearing period, it is best to cut 
down on the fragment before union commences and secure it in 
place with wire or some other form of suture material. Fracture 
or dislocation of the coccyx calls for immediate reduction to relieve 
the suffering and if necessary opiates should be used in addition. 
All of the displacements except the anterior show little or no tend- 
ency to recurrence and not much in the way of treatment will be 
required aside from reduction and relief of pain. The patient 
should be kept in bed for a week or so or until the extreme tender- 
ness has subsided. During this time the use of a pneumatic ring 
will add greatly to the patient's comfort. In fracture or disloca- 
tion with anterior displacement it is difficult to keep the fragment 
in reduction, because of the muscles attached to the coccyx. The 
condition has been treated by packing the rectum and the exhibition 
of opiates to produce constipation. If a large rubber tube, rolled in 



508 FRACTURES AND DISLOCATIONS 

gauze, is introduced it will allow the escape of flatus and liquid 
feces without removing the dressing. "When this dressing is used 
the bowels should be kept liquid by laxatives. In any case the 
rectal packing will have to be maintained until the callus is suf- 
ficiently firm to prevent the recurrence of deformity. It should 
be renewed often enough during the after-treatment to keep the 
parts clean and avoid rectal irritation. Vaseline facilitates intro- 
duction and is less irritating to the mucosa than plain gauze. If 
these measures do not control the tendency toward displacement or 
pain following the injury persists and defecation is painful because 
of the anterior displacement, excision of the coccyx is indicated and 
will be followed by relief and no disturbance in function. 




Fig. 568. — Plaster of Paris double spica of trunk and both thighs for the treat- 
ment of fracture of the pelvis. The thighs should be slightly flexed and abducted to 
allow proper care of the patient and use of the bed pan. 

In the above isolated fractures of the pelvis the patient may be 
made comparatively comfortable by rest in bed and proper nursing, 
but when the rmg of the pelvis is fractured the condition is much 
more serious and difficult to treat. The element of importance in 
separation of the symphysis, fracture of the puhic and ischio-puhic 
rami, lateral fracture of the pelvis and separation of the sacro-iliac 
joints is the breaking of the pelvic girdle and the likelihood of 
visceral complications. The indications, therefore, in the treatment 
of these conditions will be to secure immobilization of the pelvic ring 
and provide for the complications as soon as they are recognized. 
The various visceral complications are not peculiar to any one form 
of fracture of the pelvic ring and because of this fact they will be 
considered under a separate heading (see page 509). A Bradford 



FRACTURES AND DISLOCATIONS OF PELVIS 509 

bed-frame or some substitute is essential to prevent disturbing the 
fragments whenever the bed-pan is used and to keep the bed and 
patient properly clean. In place of the Bradford bed-frame we may 
employ a double plaster of Paris spica extending from the waist to 
the knees, and in this manner the pelvis is secured so that the patient 
may be rolled from side to side, the bed-pan used and the clothes 
changed without disturbing the parts or increasing the suffering. 
The cast should be applied with the thighs slightly abducted and 
with moderate flexion at the knees and hips, thus giving ready access 
to the anal region and the genitals, besides securing a more com- 
fortable position for the patient. Traction on the thigh may reduce 
deformity when the portion of the ring to which the femur is 
attached is driven in. By manipulation it is sometimes possible to 
correct some of the displacements. The treatment of fracture of 
the pelvic girdle consists mainly in the treatment of the complica- 
tions which accompany the condition. 

Complications. — Complications very rarely occur except in cases 
in which the pelvic girdle is fractured, but their presence in isolated 
fracture of some of the bones of the pelvis or even in cases of 
abdominal or perineal trauma without fracture should not be lost 
sight of. The visceral injuries accompanying fracture of the 
pelvic girdle are far more important than the fracture itself, being 
responsible for the high mortality following this fracture. Rupture 
of the urethra, rupture of the bladder, rupture of the bowel, injury 
to vessels (especially the external iliacs) and injury to nerves 
(especially the sacral and coccygeal) are among the complications 
most common in fracture of the pelvis. Renal injury sometimes 
occurs as an associated condition. 

The symptoms of rupture of the urethra will depend on the region 
of the canal injured. Injury is most frequently sustained in the 
membranous portion, as the canal emerges from the superficial 
layer of the triangular ligament. If the tear in the urethra is 
outside the cut-off muscle the hemorrhage from the meatus will be 
more or less continuous. There is often a dribbling of blood for 
some time following the accident, which grows less and finally stops 
only to begin again when urine is passed or micturition attempted. 
Pain and tenesmus are usually pronounced. Swelling of sudden 
onset, due to urinary accumulation, is seen in the perineum and if 
not relieved soon extensively infiltrates the surrounding tissues. 
The catheter usually meets obstruction when it encounters the site of 



510 FRACTURES AND DISLOCATIONS 

rupture. If the floor of the urethra is torn catheterization may 
sometimes be accomplished by following the roof with a metal instru- 
ment. Complete tear almost always requires operative intervention 
to enter the bladder. If the rupture is behind the cut-off muscle the 
blood will flow back into the bladder, appearing at the meatus only 
with micturition. If the rupture is complete, retention is the rule 
wdth occasional dribbling of bloody urine. When retention is 
present the symptoms of distended bladder will supervene within a 
few hours. The diagnosis of rupture of the urethra is made on the 
symptoms enumerated above. In some instances the tear in the 
urethra may be inspected by means of the urethrascope or posterior 
endoscope or better still the cystourethrascope. 

Treatment of rupture of the urethra. — In rupture of the urethra 
the prime indication is for prompt, continuous and complete drain- 
age of the bladder. Cases in which the passage of the catheter has 
been possible have been successfulh^ treated by means of continuous 
catheterization and suction apparatus. By far the safest method 
however consists in prompt external urethrotomy followed by 
direct drainage of the bladder through a rectal tube in the perineum 
connected by means of rubber tubing with a bottle beneath the 
bed. Perineal drainage instituted early will accomplish more in 
preventing urinary infiltration than anj^thing else. When the tear 
is complete the roof of the urethra should be brought together and 
secured by suture during the operation. The most satisfactory 
catheter in these cases is the rectal tube. In some instances consid- 
erable difficulty is experienced in finding the proximal end of the 
torn urethra and in such cases it is better to enter the bladder supra- 
pubically and do a retrograde catheterization rather than to pro- 
long the search in the perineum with the patient already suffering 
considerable shock from the accident. During the treatment of 
this condition it is always advisable to determine the condition of 
the bladder to avoid overlooking complications of this viscus. 

Symptoms of rupture of the hladder. — Shock is always a prom- 
inent symptom aside from the shock occurring in fracture of the 
pelvis. Pain is pronounced 'and tenderness present. If the rupture 
is extraperitoneal the patient passes bloody urine which is not pre- 
ceded by blood as in urethral injury. Suprapubic swelling due to 
infiltration of urine into the space of Retzius makes its appearance 
a few hours following the injury. When the rupture is intra- 
peritoneal the urine passes from the bladder into the peritoneal 



FRACTURES AND DISLOCATIONS OF PELVIS 511 

cavity and accordingly the viscus does not become distended. If 
sufficient urine collects in the abdominal cavity, dullness on percus- 
sion may be noted in the flanks. The patient is unable to pass urine 
although tenesmus is present and frequent painful attempts at 
micturition are made. 

Diagnosis of rupture of the Madder will be followed by the 
symptoms peculiar to this injury as described above. In addi- 
tion we may test the walls of the bladder by introducing a 
measured quantity of sterile salt solution through a catheter and 
remeasuring it after it has been withdrawn. If the bladder has 
been ruptured intraperitoneally it will be impossible to fill the 
viscus, and the fluid when withdrawn will be much less than the 
quantity introduced. When the rupture is extraperitoneal the loss 
of fluid will often be too small to detect. The catheter should not 
be introduced further than is necessary to reach the bladder since 
in some cases of intraperitoneal rupture it may pass through the 
rent in the bladder into the peritoneal cavity, thus evacuating urine 
which has escaped from the bladder or salt solution which has 
been introduced for diagnostic purposes. This method is not ideal 
and has been condemned by some genito-urinary surgeons, yet it 
is the best we have and nothing is more fatal to the patient than 
the expectant plan of treatment followed because of ignorance of 
the conditions present. The questionable damage done by the 
passage of salt solution (previously sterilized) from the ruptured 
bladder into the abdominal cavity and followed by operation is 
more than outweighed by the benefit the patient derives from a 
positive diagnosis and prompt surgical treatment. The cystoscope 
is valueless in intraperitoneal rupture since the bladder cannot be 
distended. AVhen the rupture is extraperitoneal it will sometimes 
be possible to inspect the injury by means of this instrument in 
competent hands. The hemorrhage, however, is usually sufficient 
to obscure the water with which the bladder is distended, so rapidly 
that vision is rendered unsatisfactory or impossible. 

Treatment of rupture of the Madder. — Rupture of the bladder 
calls for immediate operative intervention if we expect to save 
the patient. In the intraperitoneal form of rupture the rent must 
be closed through an abdominal incision and the bladder drained 
from below through a permanent perineal tube to prevent disten- 
tion of the viscus and tension on the sutures. In extraperitoneal 
rupture the tear is frequently situated in the lower anterior aspect 



512 FRACTURES AND DISLOCATIONS 

of the bladder or the re^on of the trigone, and should be repaired 
with fine absorbable sutnre material. The situation, however, of 
these extraperitoneal tears is inaccessible and difficult to operate 
upon and the condition of shock in which w^e find the patient often 
precludes any prolonged operation or anesthetic. It is therefore 
best in many cases of extraperitoneal tear to establish free perineal 
drainage at once, leaving the rent to take care of itself. 



PART III. 
LOWER EXTREMITY. 



CHAPTER XXXVI. 

DISLOCATIONS OF THE HIP. 

Surgical Anatomy. — The hip- joint is a typical ball-and-socket 
articulation, and the depth of the acetabulum is such that the 
integrity of the joint is much less dependent upon the ligaments 
than is the case in the shoulder-joint. Numerous muscles are at- 
tached to the upper end of the femur and the great trochanter, 
all of which exert more or less of an upward or inward pull, their 
action being much more apparent in fracture of the neck of the 
femur than in dislocations of the hip. The muscle of greatest im- 
portance in this region is the obturator internus which is inserted 
into the digital fossa after having emerged from the pelvic cavity 
through the lesser sacro-sciatic notch. If the head of the bone 
passes under this tendon we have the sciatic form of dislocation. 
When it passes over the muscle we have the iliac type in which the 
head of the bone rests on the dorsum ilii. The hip has five liga- 
ments : ligamentum teres, the capsule, the cotyloid, transverse, and 
ilio-femoral. The ligamentum teres passes from the ovoid depres- 
sion on the head of the femur to the margins of the fossa acetabuli. 
The capsular ligament surrounds the joint, is attached at its inner 
end to the margins of the acetabulum, while the opposite end is 
attached to the femoral neck. The anterior portion of the capsule 
extends downward and outward as far as the spiral line of the 
femur, while the posterior portion of this ligament reaches to 
within a half inch of the posterior intertrochanteric line. The 
capsule is lined with synovial membrane and possesses a number 
of accessory thickenings along the lines of the greatest and most 
frequent strains. The upper and anterior portion of this tube- 
like ligament is the heaviest. The posterior inferior portion is 
comparatively thin, loose and lax. The cotyloid ligament is an 
intracapsular fibro-cartilaginous ring attached to the margins of 
the acetabulum; it serves to deepen the cavity and strengthen the 
joint. Where it crosses the cotyloid notch, it is known as the 
transverse ligament. The above ligaments are all more or less 

515 



516 



FRACTURES AND DISLOCATIONS 



essential factors in the hip, but the ligament of b}^ far the greatest 
importance is the ilio-femoral or Y -ligament of Bigeloic. This con- 
sists of an accessory thickening in the anterior portion of the cap- 
sule. Its lower extremity is attached to the anterior intertro- 
chanteric line, while its upper end is attached, with the straight 
head of the rectus, to the anterior inferior iliac spine. In exten- 
sion of the thigh this ligament is tense, and limits motion at the 
hip ; in flexion it is relaxed. In a person of average build it is 




Fig. 569. — The ilio-femoral or Y-ligament of Bigelow, 
dislocations of the hip. 



most imijortaut structure in 



said to possess a tensile strength of two hundred and fifty pounds 
or more, and thus it will be readily understood that this ligament 
is rarely torn in dislocations of the hip. 

The head of the femur when displaced may lie anywhere about 
the acetabulum, depending on the manner in which violence was 
applied at the time of the accident, and the subsequent action of 
the muscles and ligaments attached to the bone. Although the 
head may lie in almost am- position around the acetabular ring, 
yet it almost invariably leaves the joint through a rent in the lower 



DISLOCATIONS OF THE HIP 517 

portion of the capsule. After escaping from the socket it usually 
rides upward either in front of, or behind the acetabulum. Ac- 
cordingh^ numerous classifications have been given of dislocations 
of the hip, all of them based on the position occupied by the dis- 
placed head. There are two main groups deserving of consider- 
ation, namely, anterior and posterior. The resultant attitude as- 
sumed by the lower extremity is purely a question of mechanics, 
depending upon the relations of the displaced head and the influ- 
ence of the Y-ligament. Whatever position the femoral head may 
find, the distance between the anterior inferior spine and the spiral 
line cannot exceed the length of the ilio-femoral ligament. The 




Fig. 570. Fig. 571. 



^ig. 570. — Iliac dislocation of the hip. The higher the head rests on tlie iliani 
Lore pronounced will be the inward rotation of the thigh provided the Y-ligament 



Fi^ 

the more pn 

is not ruptured. 

Fig. 571. — Sciatic dislocation of the hip. The head rests in the sciatic notch. 



action of this ligament, under these conditions, might be likened 
to that of a ''toggle joint" or ''shackle," which, though movable 
at one end, maintains a more or less fixed relation between the 
attached objects. If the head, therefore, is displaced outward and 
backward, the knee must of necessity come forward and inward, 
and in like manner the other characteristic deformities accom- 
panying the various dislocations of the hip, may be readily under- 
stood if one appreciates the anatomy, particularly the action of 
the ilio-femoral ligament. 

A second element in the production of deformity is the angle 
at which the femoral neck joins the shaft, and the consequent 



518 



FRACTURES AND DISLOCATIONS 



leverage exerted by the ueck when the head of the bone is ont of 
the socket. Thus, if the posterior aspect of the neck lies in con- 
tact with the OS innominatum, as in the anterior displacements, 





Fis:. 573. 



Fig. 572. — Ilio-pectineal dislocation of the hip. 
Fig-. 573. — Pubic dislocation of the hip. 




Fig. 575. 



Fig. 574. — Obturator or thyroid dislocation of the hip. 

Fig. 575. — Perineal dislocation; an exaggeration of the obturator type. 

outward rotation must be the result; when the reverse condition 
is true, the anterior surface of the neck lying in contact with the 
hip bone, as in posterior dislocations, inward rotation of the thigh 
will be present. The depth of the socket and the heavy ligaments 



DISLOCATIONS OF THE HIP 



519 



surrounding the joint account for the extreme rarity of disloca- 
tion of this articulation. 

If the antero-superior iliac spine be connected by a line with 
the most prominent portion of the tuber ischii, the acetabulum 
will be approximately bisected, the line passing just across the 
tip of the great trochanter. This is known as Nelaton's line and 
forms the dividing line between anterior and posterior luxations. 




Fig. 576. — High dorsal dislocation of the hip with eversion or outward rotation 
which is only possible when the outer arm of the Y-ligament is ruptured. 



If the head lies posterior to this line the condition will be known 
as a posterior dislocation and the exact position at which the head 
comes to rest will determine the type of backward luxation present. 
In like manner anterior dislocations are subdivided according to 
the point at which the head comes to rest in front of Nelaton's 
line. The more usual dislocations occurring at the hip may be 
classified as follows: 



Posterior luxations 



Anterior luxations 



rlliac 
I^Sciatic 

Ilio-pectineal 

Pubic 

Obturator 
-Perineal 



520 FRACTURES AND DISLOCATIONS 

Extreme and unusual conditions sometimes occur but for prac- 
tical purposes it is inadvisable to attempt their consideration in a 
classification. In eases of great violence, in which the Y-ligament 
is torn, the head may lie anywhere in this region and the symp- 
toms accompanying the dislocation will be atypical. The condition 
may, in rare instances, be compound or complicated b^' fracture. 

Etiology. — Dislocations of the hip constitute from one to two 
percent of all luxations. The}' occur most frequenth^ between the 
fifteenth and forty-fifth years, although they may be seen at any 
age. The increasing brittleness of the bones as age advances, ren- 
ders dislocation extremely uncommon in the aged. It occurs about 
eight times more often in males than in females. Of the various 
types of displacements, the dorsal iliac is by far the most common. 
Next in order of frequency is the obturator, a subdivision of the 
anterior. 

Symptoms. — Severe, sickening, localized pain, loss of function, 
and restricted mobility are symptoms which are common to all 
forms of dislocation of the hip. Deformity, however, will vary 
with the position occupied by the displaced femoral head. 

In the iliac type, the head of the bone lies above and behind the 
acetabulum, being prevented from occupying a higher position by 
the restraining action of the untorn ilio-femoral ligament. The 
thigh is slightly flexed, rotated inward, somewhat adclucted, and 
apparently shortened to the extent of about two inches. The pa- 
tient's suffering is greatly increased and rigid resistance is felt 
when passive motion is attempted, especially abduction. A com- 
plication of this condition is occasionally observed when the upper 
posterior portion of the rim of the acetabulum is fractured, and the 
fragment displaced with the head. Under these circumstances, the 
head leaves the socket at the point of fracture instead of through 
the usual rent in the lower part of the capsule. Reduction may be 
possible by simple traction, since the obstructing portion of the 
acetabular rim is no longer intact. Crepitus may occur as the 
serrated surfaces pass, often rendering the condition extremely 
difficult to differentiate from fracture of the femoral neck. The 
condition might, more properly, be described as a fracture of the 
acetabulum, complicated by dislocation. In iliac luxation of 
the hip there is no tendencj^ towards spontaneous recurrence of 
deformity following reduction, unless the condition is complicated 
b}' fracture of the acetabular rim. In simple dorsal dislocations, 



DISLOCATIONS OF THE HIP 



521 



passive flexion of the thigh meets with less resistance than motion 
in any other direction. Loss of function is complete. There are a 
few reported eases of dorsal dislocation with eversion of the thigh 
as a result of laceration of the anterior arm of the Y-ligament. 

The head of the hone may lie in the sciatic notch, instead of on 
the dorsum of the ilium, the condition then being known as the 
sciatic form of posterior dislocation. Under such circumstances, 




Fig. 571 



Fig. 5 77. — -Attitude in dorsal luxation of the hip. Thigh shortened, adducted and 
rotated inward. 

Fig. 578. — Attitude in anterior luxation of the hip. Thigh lengthened, abducted and 
rotated outward. 



flexion and adduction of the thigh will be more pronounced. We 
have practically the same dislocation whether the head lies in the 
sciatic notch, or on the dorsum ilii, the difference being one of 
degree only. As previously explained, the determining factor be- 
tween these two types of posterior dislocation, is the obturator 
internus. 

The symptoms in forward dislocation are the same as those just 
described as far as pain and loss of function are concerned. The 



522 



FRACTURES AND DISLOCATIONS 



deformity, however, is unlike that seen in posterior luxations be- 
cause of the difference in the positions occupied by the head. 

In the ilio-pectmeal luxation, the head rests on the horizontal 
ramus of the pubis, in the region of the ilio-pectineal eminence, in 
which position it may be palpated. Outward rotation is marked, 
though abduction and flexion are slight, if present at all. The 
capsular rent is in the lower or lower anterior portion of the liga- 
ment. Numbness and pain may be present along the course of 
the anterior crural nerve if pressure has been exerted upon it by 
the displaced head. Pressure upon or injury to the femoral ves- 




Fig. 579. 




Figs. 579 and 580. — Old unreduced dorsal dislocation of left hip of thirty-tive years' 
standing. Patient unable to fully extend thigh though able to get about by the aid of 
a built-up shoe and cane. Note the shortening, adduction and inward rotation of 
thigh. The shortening is more pronounced than is usual in recent cases. (Toes of 
left foot lost through freezing.) 



sels has been observed in some instances. Slight shortening of the 
lower extremity usually exists, and passive motion, especially in- 
ward rotation, meets with solid resistance. 

If the head of the bone continues further in its inward course, 
it may come to rest on the symphysis pubis or above the horizontal 
ramus, the dislocation then being spoken of as symphyseal or supra- 
pubic. These two conditions are but exaggerated forms of the 
ilio-pectineal luxation, and accordingly the symptoms will be more 
pronounced and the danger to the anterior crural nerve and femoral 
vessels is greater. In either of these forms the head of the bone 



DISLOCATIONS OF THE HIP bZ6 

may be felt as a globular prominence somewhere along the hori- 
zontal ramus of the pubis. 

A few cases have been reported in which the head occupied an 
extremely high position, directly below the anterior superior iliac 
spine. This is but a variation of the ilio-pectineal form, and is 
exceedingly rare. 

In the o'hturator dislocation, another form of anterior displace- 
ment, the head of the bone fails to ride upward after leaving the 
acetabulum but comes to rest in the obturator foramen. This form 
of dislocation is next, in point of frequency, to the iliac type. 
The limb is slightly flexed, abducted, and rotated outward, and 
the displaced head may be palpated without difficulty. A depres- 
sion is noted in the position formerly occupied by the trochanter, 
the thigh appears lengthened and full extension is not possible. 

The perineal luxation is simply an exaggeration of the obturator 
form of displacement, in which the symptoms (especially abduc- 
tion) are more pronounced. The condition is very unusual. The 
prominence produced by the head may be recognized both by in- 
spection and palpation. The ischio-pubic rami may be fractured 
as the head passes across this portion of the pelvis into the perineum. 

There is an extremely rare form of downward luxation known 
as the infra-cotyloid, which is analogous to the luxatio erecta oc- 
curring in the shoulder. The head of the bone is forced from the 
acetabulum while the thigh is in extreme flexion, and rests in dis- 
placement on the body of the ischium. The thigh is maintained in 
extreme flexion until the head is replaced. This condition can 
neither be classed with the anterior, nor with the posterior dislo- 
cations, since the head is crossed by Nelaton's line. This luxation 
is so extremely rare that it might better be considered as a surgical 
anomaly rather than to describe it as a type. 

Another very unusual displacement is known as central dislo- 
cation of the hip, in which the head is driven through the bottom 
of the acetabulum. This condition has already been described on 
page 504 under ' ' Fractures of the Lateral Portions of the Pelvis. ' ' 

Diagnosis. — The diagnosis is based on the symptoms just de- 
scribed. Recognition of the condition is seldom really difficult, 
although it is not uncommon to see a dislocation of the hip mis- 
taken for fracture of the femoral neck, or even confounded with 
some forms of pelvic fracture. The fact that the usual impacted 
fracture of the neck of the femur should not be broken up, renders 



524 FRACTURES AND DISLOCATIONS 

it essential that the surgeon be at least reasonably sure of the 
existing conditions before an attempt is made at the reduction of 
a luxated hip. In fracture of the neck with impaction, the lower 
extremity lies in a helpless attitude, shows some shortening and 
slight outward rotation. There is no abnormal fixation of the 
parts aside from that produced by reflex muscular spasm. Inward 
rotation is extremel}^ rare in fracture of the femoral neck. The 
most common dislocation of the hip is the dorsal, in which adduc- 
tion and inward rotation are pronounced. 

The great majority of dislocations are on to the dorsum of the 
ilium or into the obturator foramen, and the characteristic de- 
formities accompanjdng these displacements will- suggest the con- 
dition when the case is first inspected. In dislocations it will 
usually be possible to palpate the femoral head, which is, of course, 
impossible in fractures of the neck. In dislocations, mobility at 
the hip is much restricted in contradistinction to the normal mo- 
bilit}^ seen in impacted fractures, and the increased mobility occur- 
ring in fractures of the unimpacted type. In dislocations crepitus 
is absent ; in fractures it can almost invariably be elicited. Dorsal 
dislocation with fracture of the acetabular rim, may be quite diffi- 
cult to differentiate from fracture of the femoral neck. Crepitus 
ma}^ be present in either injur}'. In the former, motion is re- 
stricted as in all uncomplicated dislocations of the hip, while in 
the latter, it may be restricted or abnormally increased. Reduc- 
tion of a simple dorsal dislocation is only accomplished by some 
system of manipulations, such as Bigelow's, while on the other 
hand, displacement accompanying fracture of the acetabular rim 
may be reduced without difficulty by simple traction and counter- 
traction, and there is a strong tendency towards spontaneous re- 
currence of deformity. 

In fractures it is almost always possible to rotate the thigh, and 
with the finger placed on the trochanter, the arc described by the 
femoral neck can be ascertained and compared with the uninjured 
side, and the surgeon can estimate whether or not the center of 
this arc is in the acetabulum. In dislocations the fixity of the 
thigh precludes anything but the slightest rotation. When doubt 
exists as to the nature of the injury the X-ray should be employed 
to clear up the diagnosis. 

Treatment. — The first indication of treatment is the reduction 
of the displaced head. The method of accomplishing this purpose 



DISLOCATIONS OF THE HIP 



525 



must, of necessity, vary with the type of dislocation present. The 
object in all instances is to cause the head to retrace the course 
taken by it in leaving the cavity. All manipulations must be 
performed with due appreciation of the strength and attachments 
of the ilio-femoral ligament (see ' ' Anatomy, ' ' page 516) . It should 
be distinctl}^ understood that the common, dorsal dislocation can- 
not be dragged back into position by simple traction and counter- 
traction without the employment of excessive and unnecessary force 
and rupture of the ilio-femoral ligament. Reduction must be ac- 
complished by manipulation. 




Fig. 581. — Reduction of the common backward dislocation of the hip (see text). 
In Bigelow's method the thigh is flexed to a right angle, adducted, rotated inward, 
'lifted, circumducted outward and extended. The lifting of the thigh is the essential 
step in the reduction of backward dislocations and may be aided by counter-pressure 
with the unbooted foot as shown in this plate. In Bigelow's method of reducing an- 
terior luxations the thigh is flexed to a right angle (as shown in this illustration), 
abducted, rotated inward, adducted and extended. This modification is readily under- 
stood if the position of the head in anterior luxations is kept in mind. 



In reducing a dorsal dislocation, the first step consists in flexing 
the thigh to a right angle, which move relaxes the Y-ligament. 
Traction is then made in the line of the axis of the semi-flexed 
femur, which draws the head of the bone up on to and over the 
acetabular rim. Outward rotation is then performed, and the thigh 
allowed to gradually assume the horizontal, or extended position. 
The head of the bone should slip back into the socket as outward 
rotation is commenced, or during the first part of extension. The 
most essential part of this manipulation (Bigelow's method) con- 
sists in drawing the femoral head forward from the dorsum of the 
ilium over the acetabular rim. 



526 



FRACTURES AND DISLOCATIONS 




Fig. 582. — Stimson's method of reducing posterior luxations. The Aveight of the 
lower extremity pulls in the direction indicated by the arrow and this alone may be 
sufficient to effect reduction. Downward pressure, however, with the hand, as shown, 
Avill render the method more certain. (See text.) 




Fig. 583. — Author's modification of Bigelow's method. The thigh is "lifted" (raised 
sky-ward) b> the surgeon's shoulder while r-nunter-pressure is exerted on the anterior- 
superior ilicK s])iii(' Tlie opposite hand exerts divert pressure on the trochanter and 
pie^ents it iKun iidinu' ardUiKl the rim of the iicetaliuhuu. (See text.) It has been the 
author s experience that ditticult cases may be handled in this way after the unmodified 
Bigelow's method has failed. An. anesthetic is often essential to the reduction of dis- 
locations of the hip, especially in M'^ell-muscled persons. 



DISLOCATIONS OF THE HIP 527 

The author has found the following original method of accom- 
plishing this result successful in instances in which the above ma- 
nipulation failed. With the hip and knee flexed at right angles 
the surgeon places his shoulder under the bend of the knee, one 
hand is placed on the anterior superior iliac spine, Avhile the oppo- 
site hand grasps the trochanter, and exerts pressure in the desired 
direction. In this position forward traction is made by raising 
the shoulder, direct manipulation is had by the hand on the tro- 
chanter, while counter-traction is exerted through the hand resting 
on the iliac spine. During this manipulation an assistant should 
securely hold the patient's ankle, thus fixing the lower leg. Ac- 
cording to instructions issued by the surgeon to his assistant during 
manipulation the ankle may be carried away from, or toward the 




Fig. 584. — Allis' method of securing- the pelvis to the floor while reducing luxa- 
tions of the hip. Three staples are driven into the floor and the pelvis secured as 
shown. 

median plane, thus producing inward or outward rotation of the 
thigh as desired. In this way the head may be controlled, and 
forced up on to the slope of the acetabulum, rather than allowing 
it to ride about the margins of the rim. (See Fig. 583.) No 
originality is claimed for the principles involved in this manipu- 
lation since it is only a modification of Bigelow's method. When, 
however, difficulty is experienced in forcing the head of the femur 
over the rim of the acetabulum this manipulation will be found 
much more efficient than the regular Bigelow's method. 

Stimson's method is as follows: The patient is placed face 
downward on a table. The injured thigh is allowed to hang over 
the edge of the table at a right angle, while the uninjured extremity 
is maintained in the horizontal position by an assistant to stead}^ 



528 FRACTURES AND DISLOCATIONS 

the pelvis. The surgeon then tiexes the knee, and the weight of 
the knee, with the muscles relaxed, is said to be sufficient to effect 
reduction. Slight rotation and downward traction will assist in 
accomplishing the return of the head to the acetabulum. This 
method works nicely in some cases, though it is by no means as 
efficient as Stimson's method of eft'ecting reduction in dislocations 
of the shoulder. 

All of the above methods are based on the same principles: 
namely, bringing the head opposite the capsular rent by flexion 
and rotation of the thigh, and then forcing the head over the 
acetabular rim and through the capsular rent by traction in the 
line of the axis of the femur. 

Allis fully appreciated the value of fixation of the pelvis and 
advises having it secured to the floor by means of a sj^stem of screw 
eyes and bandages (see Fig. 584) or else by means of assistants. 
This however will not be necessary if the author's modification of 
Bigelow's method is employed. 

The reduction of anterior displacements is accomplished by the 
same principles as already described, although the difference in 
the position of the head will necessitate different manipulations to 
bring the head opposite the capsular rent. 

The ilio-pectineal dislocation and its variations along the hori- 
zontal ramus of the pubis are reduced as follows : extension is 
made to bring the head downward as far as possible so that flexion 
can be accomplished. The thigh is then flexed at a right angle 
with the body, while direct pressure is made upon the head to 
prevent its slipping upward. Inward rotation and traction in the 
line of the axis of the femur are then performed to return the 
head to the socket. The last step in this manipulation is similar 
to that already described under dorsal dislocations. 

The obturator dislocation and its exaggerated form, the perineal 
type, are reduced in much the same manner as dorsal dislocations 
after the head has been brought opposite the capsular rim. The 
steps are : flexion of the thigh to a right angle, traction in the 
line of the axis of the femiir, and then, abduction and outward ro- 
tation. The limb is then extended. 

Central dislocations of the hip are reduced by outward traction 
on the upper end of the thigh while the knee is fixed. The condi- 
tion is more properly a fracture than a dislocation. Buck's exten- 



DISLOCATIONS OF THE HIP 529 

sion is indicated for from six to eight weeks and direct outward 
traction on the upper portion of the thigh should be maintained, 
according to the Ruth-]\Iaxwell method, to prevent the muscles 
attached to the upper femur from pulling the head through the 
acetabulum into the pelvis. (See ''Ruth-Maxwell method," page 
545.) 

The strength of the muscles and the pain accompanying manipu- 
lations renders an anesthetic essential in the reduction of hip dis- 
locations. 

Operative Treatment. — Nearly all dislocations of the hip can be 
reduced by proper manipulation under anesthesia, though occa- 
sionally it is impossible to return the head to the socket, unless 
recourse is had to operative methods. A vertical incision in the 
region of the trochanter can be so made as to expose the parts 
involved. When inward rotation is present the incision should 
be made a little behind the trochanter; when outward rotation is 
present the incision should be anterior to the trochanter to prop- 
erly expose the head and neck. A¥ith the parts opened, the cap- 
sular rent and the course taken by the head after leaving the cavity 
of the acetabulum may be readily recognized, and by the proper 
manipulation, the head may be made to retrace its course back to 
the socket. Obstructions to reduction are to be removed when 
present. With the head again in the acetabulum, the capsular rent 
should be sutured, muscular structures approximated and the skin 
incision closed. 

Old, unreduced dislocations are the ones most frequently de- 
manding operative reduction. When the head of the bone has 
been out of the socket for some time, fibrous tissue forms about it 
in such a manner that partial restoration of function results. The 
action of the thigh, however, is always more or less impaired be- 
cause, if for no other reason, the upper end of the femur is ''off- 
center" with relation to the muscles of the hip. Partial or com- 
plete healing of the capsular rent often renders it impossible to 
accomplish reduction by simple manipulation. If some months 
have elapsed since the accident the acetabulum may become filled 
with fibrous tissue, which must be removed with a heavy curette or 
chisel before the head of the bone can be made to fit it. The joint 
is approached through a lateral, vertical incision, as already de- 
scribed, which varies somewhat with the type of dislocation present. 



530 FRACTURES AND DISLOCATIONS 

Contractures in the thigh muscles sometimes necessitate transverse 
cutting of either tendons or muscles before the head of the bone 
can be returned to the socket. 

After-Treatment. — Following reduction of a recent dislocation 
the patient should be kept at rest in bed for a period of from two 
to four Aveeks, according to the age of the individual and the sever- 
ity of the condition. Massage and passive motion are of service 
in maintaining the muscular tone of the lower extremity. In the 
performance of passive motion, however, abduction should be 
avoided, since this is the position in which the head probably left 
the cavity. Central dislocations and dorsal dislocations compli- 
cated by fracture of the acetabular ring require Buck's extension 
apparatus to maintain reduction. In addition central dislocation 
calls for lateral traction of the thigh. These aj^pliances should 
be kept in use for a period of six weeks. During the after-treat- 
ment the weights employed in the traction apparatuses may be 
reduced as the muscular spasm grows less. The resumption of 
function should be gradual after the patient has recovered suffi- 
ciently to leave his bed. He should be instructed to particularly 
avoid any position of the thigh similar to the attitude in which 
dislocation occurred. 

Prognosis. — The outlook in uncomplicated dislocations of the hip 
is good if reduction is accomplished early and sufficient time allowed 
for the repair of the parts before function is resumed. Central 
dislocation of the hip is a much more serious condition, since it 
includes fracture of the pelvis and may be accompanied by injury 
to the pelvic viscera. Proper operative procedures are usually fol- 
lowed by improvement of function, though it is seldom possible to 
secure a perfect restoration, if the head of the bone has been out 
of the socket for anv considerable length of time. 



CHAPTER XXXVII. 

FRACTURES OF THE UPPER END OF TPIE FEMUR. 

Surgical Anatomy. — The upper end of the femur has three 
accessory centers of ossification ; one for the head, one for the 
greater, and one for the lesser trochanter. They all join the 
diaphysis at about the eighteenth year. Epiphyseal separations, 
however, are extremely rare in the upper end of this bone, except 
as a chronic condition in children, which is known as coxa vara. 
(See "Injuries to the Femoral Neck in Children," page 555.) The 
structure of the upper end of the femur, including the relation of 
compact and cancellous tissue, is of importance in explaining many 




Fig. 586. 



Figs. 585 and 586. — Coronal and nearly horizontal sections of the upper end of 
the femur showing the relative distribution of cancellous and compact tissue. H., head 
of femur. T., trochanter major. (Preston — Surg., Gynecol, and Obstet., Feb., 1914.) 

of the clinical conditions occurring in fractures (see Figs. 585 
and 586). The upper end of the bone is composed of wide-meshed 
cancellated tissue, enclosed in a layer of compact structure which 
grows heavier as the shaft is approached. Closer examination of 
the cancellous tissue shows that it is disposed in two sets of planes, 
the socalled "tension planes" and "pressure planes." The former 
run upward from the outer portion of the shaft into the trochanter, 
and arch over into the neck and head; the latter ascend from the 

531 



532 FRACTURES AND DISLOCATIONS 

inner side of the shaft and pass into the head, while others arch 
over to the great trochanter. These planes are simply an arrange- 
ment of the cancellous tissue which renders the same amount of 
bone more capable of withstanding the pressure and tension to 
which the femur is subjected by use. The calcar femorale is a 
thickening in the internal structure of the neck which strengthens 
the angle of junction between neck and shaft. 

The neck joins the shaft at an angle of about 127 degrees, al- 
though variations occur between the limits of 121 and 141 degrees. 
In children the angle is more obtuse, while in old age it approaches 
the right angle. The great trochanter is often traversed by a 
continuation of the compact tissue of the posterior surface of the 
neck, and although this tends to strengthen the posterior aspect 
of the neck, yet the arrangement is not as strong as that found 
anteriorly. 

Numerous muscles are attached to the upper end of this bone, 
which influence the relative positions of the fragments in the pres- 
ence of unimpacted fracture of the neck. Raising of the lower 
fragment or, in other words, shortening of the lower extremity, is 
brought about by the action of the ham-string muscles, the adductor 
group, the glutei, rectus, sartorius, ilio-psoas, tensor vaginae femoris, 
pectineus and gracilis. Eversion of the lower extremity is the 
result of the weight of the thigh, the center of gravity being ex- 
ternal to the articulation of the hip. Eversion, in impacted cases, 
is due to the manner in which the base of the neck is driven into 
the trochanter and the fact that the anterior portion of the femoral 
neck is stronger than the posterior. In addition to the action of 
the pectineus and the adductor muscles, it will be observed that all 
the glutei tend to produce outward rotation. 

Fractures may occur in the neck, close to the head, midway be- 
tween the head and the great trochanter, or at the base of the neck 
where it joins the shaft. The last named position is by far the 
most common. In some instances the fracture may pass in such a 
manner that it involves the upper portion of the femoral shaft as 
well as the neck. Fractures have been divided anatomically ac- 
cording to the position of the break with relation to the capsule. 
Intra-capsular fractures show a much stronger tendency toward 
non-union than those outside the capsule. Surgically, however, 
this distinction is not of gTeat value, since it is almost impossible 
in a given case to say whether the fracture is within or outside of 



FRACTURES OF UPPER END OF FEMUR 533 

the ligament. jMoreover, post-mortem findings have demonstrated 
the fact that in the majority of instances in which the neck is 
broken, the line of fracture is both intra- and extra-capsular ; that 
is, the fracture passes through the femoral attachment of the liga- 
ment. The more practical distinction is whether or not the frac- 
ture is impacted. Impaction consists, as a rule, in the base of the 
neck being driven into the substance of the great trochanter. If 
the neck is viewed from above one reason for the frequency with 
which eversion accompanies impaction will be apparent. The an- 
terior surface of the neck is almost straight and flush with the 
front edge of the trochanter, thus offering solid support to the 
anterior portion of the trochanter in the presence of direct vio- 
lence. The posterior surface of the neck is much curved and does 
not come flush with the posterior margin of the trochanter. This 
results in the posterior portion of the trochanter being much more 
poorh^ supported than is the anterior, and when direct violence 
is applied in this region of the bone the posterior aspect of the 
neck will be more likely to give way than the anterior. The result 
is, manifestly, eversion when impaction of the femoral neck occurs. 
The continuation of the compact tissue of the posterior surface of 
the neck into the trochanter, previously mentioned, tends to 
strengthen this portion of the bone ; yet this bony tissue is variable 
and even when present is not sufficiently heavy to increase the 
strength of the posterior aspect of the femoral neck so that it equals 
that found in the anterior portion. When the ring of compact 
tissue surrounding the junction of the neck and shaft is fractured, 
the neck crushes into the cancellous tissue of the trochanter with 
comparatively little resistance. 

The surgeon should know the bony landmarks in this region to 
be able to properly diagnose and treat fractures of the femoral 
neck. The crest of the ilium is subcutaneous throughout, the great 
trochanter can be recognized both by inspection and palpation, 
and the tuberosity of the ischium can be readily felt. The rela- 
tive positions of the anterior superior iliac spine, tuber ischii and 
trochanter major should be known under normal conditions in 
order that the variations occurring in fractures may be recognized. 
If a tape is stretched between the anterior superior iliac spine and 
the tuberosity of the ischium it will correspond to Nelaton's line 
(see Fig. 587). Normally Nelaton's line about touches the top of 
the great trochanter. In fracture of the femoral neck with short- 



534 



FRACTURES AND DISLOCATIONS 



ening, the top of the trochanter rises above this line. The fascia 
lata, composed of heavy fibrous tissue, is attached above to the 
outer lip of the iliac crest, and below to the external tuberosity of 
the tibia. Under normal conditions this fascia is tense and offers 
resistance when pressure is made between the iliac crest and tro- 
chanter; when fracture or disease of the femoral neck results in 
shortening, this portion of the fascia lata becomes lax, which con- 
dition may be recognized by comparison with the opposite side. 

The rarifying changes or osteoporosis occurring in old age affect 
the entire internal structure of the upper end of the femur, and 
tend to remove the calcar femorale, and the extension of the pos- 
terior surface of the neck which continues into the substance of 
the trochanter. In addition, the surface compact tissue becomes 




Fis:. 587. — Mapping out of Bryant's triangle and Nelaton's line. A line drawn 
from the anterior superior iliac spine to the tuberosity of the ischium is known as 
Nelaton's line and should about touch the top of the great trochanter. (See Fig. 600.) 
A vertical line dropped from the anterior superior iliac spine to the table on which 
the patient lies and a vertical line extended upward from the top of the great trochanter 
form two sides of Bryant's triangle while the third side is formed by Nelaton's line. 
Bryant's triangle — X.Y.Z. In fractures of the femoral neck the distance Y.Z. is 
usually shortened. A.S., the anterior superior iliac spine. S., Symphysis pubis. T.I., 
Tuber ischii. 



thinner and more brittle. These changes together wdth the alter- 
ation in the angle at which the neck joins the shaft explain, at 
least partially, the frequenc}^ of fracture of the femoral neck in 
the aged. 

Fracture of the head of the femur is an extremely unusual con- 
dition, only two or three cases having been reported. It is not an 
uncommon matter for fractures of the neck of the femur to involve 
the great trochanter, but isolated fracture of the trochanter is 
almost as rare as fracture of the head. The cases reported have 
been due either to direct violence or to muscular action. Isolated 
fracture of the lesser trochanter is also a rare condition. The re- 
ported cases seem to have been due to the action of the ilio-psoas. 

Etiology. — Fracture of the neck of the femur is essentially an 
accident of advanced life. Fractures of the femur constitute 



FRACTURES OF UPPER END OF FEMUR 



535 




Fig. 5SS. — Impacted fracture (if linse of femoral neck. 

Fig. 589. — Old ununited fracture of midillc of fesiioral neck with upward displace- 
ment of lower fragment. Tlie upward displacement nf the femur is plainly visible and 
the manner in which the fascia lata becomes lax betAveen the trochanter and iliac crest 
is readily appreciated. 




Fig. 591. 



Fig. 
Fig. 



590. — Impacted fracture of neck of femur. 

591. — Fracture of femoral neck with usual deformitv- 



•aising of trochanter. 



536 



FRACTURES AND DISLOCATIONS 




Fig. 592. 



Fig. 593. 



Fig. 592. — Fracture of rim of acetabulum. Upper arrow points to line of fracture 
while the lower indicates the detached fragment. Deformity controlled by Buck's exten- 
sion. 

Fig. 593. — Fracture of a small portion of the great trochanter with separation of 
the fragment. Result of muscular action. A condition which might readily be over- 
looked and considered as a "sprain" if the X-ray were not employed. 




Fig. 594. 



Fig. 595. 



Fig. 594. — Fracture through femoral neck about midway between head and tro- 
chanter. Deformity overcome by Buck's extension. 

Fig. 595. — Fracture through base of femoral neck with splitting off of lesser tro- 
chanter. 



FRACTURES OF UPPER END OF FEMUR 537 

about six percent of all fractures, and fractures of the neck of the 
bone make up from one-third to one-fourth of all femoral frac- 
tures. ]\Iore than half of the fractures of the neck occur after the 
sixtieth year. They are more common in women than in men. 

Symptoms. — The physical signs and symptoms in fracture of the 
femoral neck vary according to whether or not impaction exists. 
In the unimpacted form the patient is unable to stand on the in- 
jured member. In fact the lower extremity lies in an entirely 
helpless attitude. Pain is constant, and increased on motion. The 
limb is usually completely everted so that the outer surface of the 
foot rests flat on the bed. The great trochanter is raised above 
Nelaton's line, and the fascia lata between the trochanter and iliac 
crest is found relaxed when compared with the opposite side. In- 
version of the limb, though extremely rare, may be present, instead 
of eversion. Crepitus and mobility may be elicited, but all manip- 
ulation should be most gentle and guarded, lest impaction, if 
present, be broken up. Rotation is particularly likely to loosen 
the impaction. The limb is shortened, though seldom more than 
two inches. The shortening is usually less pronounced immedi- 
ately following the accident than it is at the end of twenty-four or 
forty-eight hours. Traction upon the foot lessens the shortening, 
though recurrence is prompt when the foot is released. A slight 
fullness in the upper portion of Scarpa's triangle is usually noted. 

"When the fracture is impacted most of the above described symp- 
toms are present though less pronounced. Slight or moderate 
eversion is usually noted, and some shortening exists though it is 
by no means as great as is commonly seen in unimpacted cases. 
Crepitus is absent. Pain is usually present, though the degree is 
quite variable. Loss of function is by no means as constant and 
pronounced as in unimpacted fractures. In fact, a patient with a 
firmly impacted fracture of the femoral neck may be able to walk 
a considerable distance. This incomplete loss of function has not 
infrequently been the cause of incorrect diagnoses, the condition 
having been mistaken for a ''sprain." Impaction of the fracture 
produces some shortening of the femoral neck, which may some- 
times be recognized in the shorter arc described by the trochanter 
when the thigh is rotated. This shortening, how^ever, is often so 
slight that it is difficult of recognition, and since rotation is so 
likely to break up impaction it will usually be best to pass lightly 
over this symptom. The history given in the usual case of frac- 



538 



FRACTURES AND DISLOCATIONS 




Fig. 596. — Impacted fracture of the femoral neck, 
ing present and eversion is only moderate. 



Yerv slight degree of shorten- 




Fig. 597. — Impacted fracture of the neck of tlie femur in an old man. The limb 
is helpless. Very slight eversion and shortening present. There is no appearance of 
twisting of the thigh as seen in Fig. 62 6, nor is there any thickening of the thigh as 
seen in Fig. 598. Rontgenogram sho^vs fracture of the femoral neck. It is this type 
of case which is so often overlooked and diagnosed as a "sprain" especially if the pa- 
tient is able to walk. 




^ 




Fig. 598. — Fracture of right femur through great trochanter. Note thickening of 
the thigh in its upper part and the eversion of the lower extremity. Compare the levels 
of the two knees which are directly in front of the camera. Right thigh slightly shorter. 
Picture taken a few minutes following the injury. 




Fig. 599. — Fracture just below the great trochanter. Note the eversion and shortening 



FRACTURES OF UPPER END OF FEMUR 



539 



ture of the femoral neck in elderly persons is one of slight trauma, 
such as a misstep, a twist of the thigh, or a fall in walking across 
the room. It is sometimes difficult to ascertain whether the fall pro- 
duced the fracture, or whether the fracture was spontaneous and 
resulted in the fall. 

Diagnosis. — The deep position of the femoral neck, surrounded 
by heavy muscles and fascige renders palpation of this portion of 
the bone extremely difficult. The diagnosis is based on the symp- 
toms just described, together with a careful examination of the 
lower extremity including mensuration and comparison with the 
uninjured member. The X-ray is invaluable in diagnosticating 




Fig. 600. — Drawing a line between the anterior superior iliac spine and the 
tuberosity of the ischium to determine the relative level of the greater tuberosity. 
Nelaton's line. (See Fig. 587.) 

the presence of fracture ; in fact it is the only means of determining 
accurately the details of the injury. 

Nelaton's line and Bryant's triangle (see Fig. 587), should be 
mapped out and the position of the trochanter determined with 
relation to the bony landmarks of the pelvis. (See ''Anatomy," 
page 533.) The case should be carefully inspected for the purpose 
of recognizing deformity, and accurate measurements should be 
made before manipulation in any form is attempted. The distance 
from the anterior superior iliac spine to the tubercle of the femur, 
and then to the internal malleolus should be taken with a steel 
tape, and compared Avith the distances between the corresponding 
bony prominences of the opposite lower extremity. In taking these 
measurements the patient should be placed squarely in bed so that 



540 



FRACTURES AND DISLOCATIONS 



a line drawn throngli the anterior superior iliac spines will be at 
right angles to the spinal column. In other words the pelvis should 
not be "tipped" at the time the measurements are being taken. 

Fracture of the femoral neck must be differentiated from dislo- 
cations of the hip, fracture of the acetabulum with or without dis- 




Fig. 601 and 602. — Measuring the length 
of the k)\ver extremity from the anterior supe- 
rior iliac spine to the tip of the internal mal- 
leolus. The legs should be parallel and the 
pelvis should not be tipped. In other word.s a 
line drawn through the anterior superior iliac 
spines should be at right angles with the 
median plane of the body. (See Figs. 603 
and 604.) 

placement of the head, fracture of 
the pelvis, and fracture of the 
femoral shaft. 

The characteristic attitude as- 
sumed in luxations of the femoral 
head, the restricted mobility and, 
in some instances, direct palpation 
of the displaced head, should serve 
to distinguish dislocations of the 
hip from fracture of the femoral neck. In fractures of the fem- 
oral shaft the position occupied by the great trochanter will be 
found normal and the point of preternatural mobility will be lo- 
cated below it. When the thigh is rotated the trochanter will fail 
to follow the shaft. Fracture of the acetabular ring and certain 




FRACTURES OF UPPER END OF FEMUR 



541 



pelvic fractures are occasionally difficult to differentiate from 
fracture of the femoral neck unless a Rontgenogram is made. In 
fact the X-ray should be employed in almost all injuries about the 




Fig. 604. 



Fig. 603. — Measurements of the lower extremities taken with the legs parallel and 
the pelvis up-tipped. 

Fig. 604. — Shows the effect of tipping the pelvis when these measurements are being 
taken. 

hip. Inspection, palpation and mensuration may enable one to 
determine the seat of the lesion but it is impossible to ascertain 
the exact details and nature of the fracture without the aid of an 
X-ray plate. Moreover one cannot be sure, prior to examination, 




Fig. 605. — Picture taken to show how the fascia lata becomes lax between the iliac 
crest and the trochanter when the latter is raised through fracture or disease. 

whether or not impaction exists, and it is much better to refrain 
from manipulation altogether, rather than to break up an impac- 
tion. The surgeon who is unaccustomed to dealing with these 



542 FRACTURES AXD DISLOCATIONS 

cases had better submit the patient to an X-ray examination before 
any extensive manipulation is attempted. 

Treatment. — The treatment of fracture of the neck of the femur 
depends, first on the age and condition of the patient, and next on 
whether or not the fracture is impacted. As far as the fracture 
itself is concerned, recumbency is a prime requisite, but the fact 
that old persons are unable to stand prolonged confinement to bed, 
makes it necessary to adopt some form of ambulatory treatment 
or one in which the patient may be raised to the sitting position. 
When the neck of the femiTr is fractured in elderly persons the 
treatment is often more a question of the prevention of compli- 
cations, such as hypostatic pneumonia, than complete restoration of 
function in the injured member. 

There are at the present time four recognized methods of treat- 
ing fractures of the hip. They are: recumhency with traction and 
counter-traction^ the plaster cast^ the amhulatory splint and open 
treatment. Each form of treatment has its modifications, and com- 
binations of these methods are not uncommon in the treatment of 
fractures of the femoral neck. None of them is ideal ; they all 
have their advantages and their drawbacks. Each case should be 
carefully considered and the method or combinations of methods 
best suited to the case in hand should be adopted. In selecting the 
mode of procedure to be followed the surgeon must consider his 
surroundings and the available facilities as well as the age and 
condition of the patient. 

If the patient is strong enough to remain in bed during the 
process of repair the fracture may be treated by Buck's extension 
and the long side splint. It is essential that the bed be firm and 
unsagging. If a fracture bed cannot be obtained the ordinary bed 
may be made more rigid by placing boards under the mattress to 
prevent sagging. Buck's extension is applied as shown in Figs. 
606 and 607. The lower extremity is soaped, shaved, sponged 
with alcohol and thoroughly dried before the adhesive plaster 
is applied. The wooden spreader below the foot should be 
broad enough to keep the adhesive plaster from touching and 
irritating the ankles. The weights employed should be suffi- 
cient to control the muscular spasm and will vary with the build 
of the patient. Greater weight will be required during the first 
day or two than is necessary later when the muscles have been tired 
out by the continuous pull of the extension apparatus. From ten 



FRACTURES OF UPPER END OP FEMUR 



543 




Fig. 60H. — Shows adhesive phixter applied to the leg to secure longitudinal traction 
on the lower extremity. Buck's extension. 




Fig. 607. — Shows Buck's extension completed. The strips of adhesive liave been 
fastened to the spreader, and rope pulley and weight attached. The spreader consists 
of a small square piece of light board with a hole drilled through its middle for the 
attachment of a light rope. Its purpose is to prevent the adhesive plaster from coming 
in contact with the skin over the malleoli and to act as an equalizer so that the pull will 
b€ the same on both strips of adhesive. (See page 542.) 




Fig. 608. 



Fig. 609. 



bed. 



Fig. 608. — A convenient form of weight to be used with Buck's extension. 

Fig. 609. — A good adaptation of the pulley to be attached to the foot of an iron 



544 



FRACTURES AND DISLOCATIONS 



to twenty pounds may be advisable during the first few days, but 
later in the treatment six or eight pounds will usually be all that 
is necessar}^ to steady the parts and overcome the increased mus- 
cular tone. The patient will be more comfortable with a proper 
weight than with too much or too little. Counter-extension is ob- 
tained by raising the foot of the bed eight, ten or even fifteen 
inches, according to the weight used, AA^ith the extension apparatus 






Fig. 610. 



Fig. 611. 



Fig. 610. — Long T-splint used in the treatment of fractures of the neck or shaft 
of the femur. A strip of T\'ood about one foot in length may be nailed in the angle 
of the splint to prevent the bed clothes resting on the foot. This -w-iil obviate the neces- 
sity of using a cradle. (See Fig. 708.) 

Fig. 611. — A. shoAvs Buck's extension applied and T-splint in position -with appro- 
priate padding. B. shows the padding bandaged to the splint and the latter secured in 
position by means of strips of adhesive and body swathe. 



in place a long side splint is applied, the upper end extends to 
the eighth or tenth rib and is secured to the trunk by means of a 
body swathe. The thigh and leg are secured to the splint by 
means of bandages or adhesive plaster. If a cross-piece is attached 
to the lower end of the splint it will render the whole more steady 
and secure. In unimpacted cases particular care should be taken 
to correct eversion. This can be nicely accomplished by transverse 
strips of adhesive passing under the thigh and over the side splint 



FRACTURES OF UPPER END OF FEMUR 545 

to which they are fastened. If the fracture is impacted, extension 
and counter-extension should be applied with caution lest the im- 
paction be broken up. Enough weight, however, should be used 
to control the muscular spasm which is capable, in some cases, of 
breaking up the impaction, if not counteracted by the extension 
apparatus. Sand bags on either side of the limb may be used to 
advantage instead of the splint, especially in impacted cases. Ex- 
tension and counter-extension is one of the oldest methods of treat- 
ing fracture of the hip. The fixation secured in this manner is not 
as perfect as that obtained by the plaster cast or by one of the metal 
splints to be described later ; yet excellent results have followed its 
use. This method is particularly serviceable during the first week 
or ten days following the accident. It is often advisable to substi- 
tute some other form of fixation (such as the brace or cast) after 
the acute inflammatory reaction at the site of fracture has subsided, 
and the shortening has been partially or completely overcome by 
the extension apparatus. During this initial period one can de- 
termine by palpation, mensuration and the X-ray the degree of 
reduction which has been accomplished by non-operative measures 
and the advisabilit}^ of resorting to open treatment. 

The Ruth-Maxwell method is an elaboration of the above in which 
lateral traction is exerted on the upper end of the femur in addition 
to longitudinal extension and counter-extension. The longitudinal 
traction is accomplished as already described. The outward trac- 
tion on the upper end of the femur is had by means of a sling 
passed about the thigh at the level of the perineum, and then by 
the use of a cord, pulley and weight ; outward and forward traction 
is exerted, as shown in Fig. 612. Counter-extension for this lateral 
traction is obtained by raising the same side of the bed a few 
inches. In unimpacted cases the lateral traction may be made to 
overcome the backward displacement of the upper end of the lower 
fragment. Eversion of the lower extremity can be corrected by 
placing most of the pull on the posterior arm of the sling about 
the thigh. When used in this way the sling should be prevented 
from slipping about the thigh by securing it to the skin with ad- 
hesive. A number of advantages are claimed for this method : 
firstly, that the neck is maintained at a more nearly normal angle 
during the process of repair, secondly, that the patient may be 
raised to the sitting position without disturbing the fragments, and 
thirdly, that the use of the bed-pan is greatly facilitated. 



546 



FRACTURES AND DISLOCATIONS 



The advisability of employing this method is best determined in 
a given case, by ascertaining the degree of reduction which it ac- 
complishes as shown by palpation, mensuration and the X-ray. If 
in an unimpacted case the apposition is improved b}^ lateral trac- 
tion, this method is indicated. 

The plaster cast has been used with considerable satisfaction and 
may be varied to meet the needs of the case. It may be employed 
in a number of ways ; the following three types of cast will be found 
the most important. 

The straight cast is most often employed in middle aged pa- 




Fig. 613. 

Fia;. 612. — Diagram illustrating the principles employed in the treatment of frac- 
tures of the femoral neck according to the Ruth-Maxwell method. 

Fig. 613. — ShoAvs the proper distribution of sand bags to steady the lower extremity 
when the hip is fractured. 

tients; in old and feeble persons the cast is applied with the knee 
and hip flexed to about right angles so that the patient may be 
raised to the sitting position during the day; and in children it 
may be applied with the thigh in extreme abduction according to 
the principles laid down by Whitman. 

The straight cast should" extend from the waist to the toes and 
be properly lined with sheet cotton or some other material, to avoid 
irritation of the skin. If a union suit of soft, ribbed material is 
put on before the cast is applied we will have a very satisfactory 
form of lining. After the plaster has set and dried, the portion 
of the union suit not covered by the cast may be cut away. A 



FRACTURES OF UPPER END OF FEMUR 547 

stomaeli pad should he placed between the cast and the abdomen 
the same as employed with casts of the trunk. Special reenforce- 
ments of plaster-soaked gauze, tin, or cypress wood should be used 
at the groin and behind the knee where the cast most frequently 
breaks. These reenforcements are best placed between the different 
layers of the plaster bandages as the cast is being applied. The 
knee should be in a position a little short of complete extension to 
avoid subsequent discomfort in the joint. The cast should be 
heavy enough to stand the strain of the six or eight weeks of use 
to which it will be put during the after-treatment. This dressing 




Fig. 614. — Plaster cast for fracture of the hip applied with the thigh in abduction. 
A strap passing from the body portion of the cast under the perineum will add to the 
security of the fixation. An even more secure form of cast is one which includes both 
extremities in abduction. 

accomplishes fixation very nicely whether recumbent or ambulatory 
treatment is employed. If used as an ambulatory splint the shoe 
of the opposite foot should have the sole built up as is commonly 
done with the Thomas splint. The ambulatory treatment should 
not be allowed in old persons unless the surgeon is satisfied that the 
patient is not too feeble to get about with crutches without the risk 
of further fall and injury. Old and feeble persons do not stand 
confinement in bed for a period sufficient to obtain union, on the 
other hand they are often unable to get about with the added en- 



548 FRACTURES AND DISLOCATIONS 

cumbranee of a hip splint or cast. In such cases the author has had 
considerable satisfaction with the following- original method. 

The cast is applied with the hip and the knee flexed at ahout right 
angles. In other words the injured member is encased in plaster 
in the attitude normally assumed when the patient is seated. With 
the lower extremity in this position the patient can comfortably 
occupy an easy chair during the day and still rest well in bed at 
night with the flexed lower extremity properly bolstered. If a 
Morris chair is employed in the treatment, the movable back may 
be raised during the day and the foot of the injured member prop- 
erly supported on a foot stool or pillows. AVhen night comes the 




Fig. 615. — Cast of louver extremity and trunk applied -o-ith the thigh and leg 
flexed to right angles. This form of cast is of great advantage when the hip is frac- 
tured in elderly persons who are unable to stand the recumbent position. During the 
day the patient may be placed in the sitting ijosition -while at night he may lie on his 
back ■v\'ith the injured member properly bolstered. (See text.) 

back of the chair can be lowered so that the patient resumes the 
dorsal recumbent position, while the injured leg is raised and sup- 
ported by pillows, sand bags or some other arrangement. (See 
Fig. 615.) In this way he may enjoy good rest at night and still 
be in the sitting position during the day, thus avoiding the develop- 
ment of hypostatic pneumonia. If traction is made at the knee 
while the plaster is setting a fair degree of extension and counter- 
extension may be had during the after-treatment. This is made 
possible by the position of the leg which is at right angles with 
the thigh. 

The plaster cast may he employed with the thigh in extreme ad- 
duction as practiced hy Whitman. This method is particularly 



FRACTURES OF UPPER END OF FEMUR 549 

applicable in children and is based on sound mechanical and ana- 
tomical principles. By abducting the thigh the lower portion of 
the capsular ligament is made tense and the fractured surfaces (if 
engaged at all) are thus forced firmly together. This position is 
maintained by means of a plaster of Paris spica of the thigh. In 
selected cases tliis method will be productive of excellent results 
and deserves a more extended trial in adults. 

It should never be taken for granted, in a given case, that good 
reduction has been accomplished because the thigh has been ab- 
ducted and fixed in this attitude. The position of the fragments 
should be verified by the X-ray. 

The reason that this method has met with such success in chil- 
dren is due firstly, to the fact that fractures of the femoral neck 
at this period of life are seldom complete, and secondly, that ab- 
duction with the fractured surfaces opposed and firmly engaged 
tends to prevent the subsequent lessening of the angle at which 
the neck joins the shaft. In other words, it prevents coxa vara. 
If the fractured surfaces are not engaged this method is valueless. 

The Thomas hip splint has been used with considerable success 
by some surgeons. The main drawback to this splint, and others 
employing the same materials and principles, consists in the cost 
and the difficulty of obtaining the services of some one competent 
to properly make and fit it to the patient at the time it is needed. 
The surgeon is not, as a rule, equipped for this work which should 
be done by an experienced blacksmith and leather-worker. In 
most of the larger cities there are makers of surgical instruments 
and orthopedic appliances who are thoroughly qualified to produce 
and fit a satisfactory splint, but in country practice it is often 
difficult to procure the desired apparatus on short notice. 

The splint is made of soft iron and consists of a main stem or 
bar of 3/16 by 5/8 inch material which extends from the chest to 
the ankle along the posterior aspect of the trunk and lower extrem- 
ity. To this main stem is attached a chest-band, a thigh-band and 
a calf -band as indicated in the accompanying diagram (Fig. 620). 
These bands are made of strips of soft iron % by one inch, on 
cross section, and are bent into position when the splint is applied. 
Different weights of material may be used according to the size 
and musculature of the patient, and the transverse encircling bands 
may be varied in position and number according to the nature of 
the case and the fixation desired. The main stem of the splint 



550 FRACTURES AND DISLOCATIONS 

should follow the curves of the 1)ody and lower extremity, and the 
points of junction between main stem and bands should be flush, 
to avoid undue local pressure and irritation. The entire splint 
should be well padded and bound Avith leather and the anterior 
extremities of the horizontal bands connected by straps and buckles. 
By means of crutches and a built-up shoe for the opposite foot the 
patient, after some practice, is able to be up and about. It often 
requires a number of trials before he becomes sufficiently sure- 
footed under these awkward circumstances, and the surgeon should 
see that he is properly attended to prevent falling. 

When ambulatory treatment is indicated, as is the case in old 
persons from the first, and in younger patients during the second 
half of the after-treatment, the Thomas splint has served well. If 
extension is required it may be had by means of adhesive strips 
applied in a manner similar to that shown in the use of Buck's 
extension (see page 543). The lower ends of the longitudinal 
strips of adhesive are secured, under tension, to the calf bands of 
the splint. 




Fig. 616. — Author's screw plates for internal fixation of fractures of the femoral 
neck. (See Figs. 617, 618 and 619.) 

The ambulatory pneumatic splint, as shown in Fig. 621, with 
the hip attachment, has the advantage of being adjustable, so that 
it can be used on different cases, and is so constructed that it may 
be used for either hip. Extension is also provided for when needed 
(see Fig. 719). 

Operative Treatment. — The open method is indicated in non- 
impacted cases in which the fragments cannot otherwise be brought 
back into satisfactory apposition. Nailing and pegging the neck 
in place have been practiced for some years past but, because of 
the internal structure of the upper end of the femur, the end re- 
sults have not been as encouraging as might be desired. The 
cancellous tissue, through "which the screw passes, crushes so readily 
that displacement following the operation is prone to occur. The 



FRACTURES OF UPPER END OF FEMUR 



551 



manner in wliieh this takes place is indicated in Fig. 618. To 
avoid this result two screws or nails, placed at different angles have 
been used but the results following this method have been almost 
as uniforml}^ inefficient as when a single screw is employed. A 
much more satisfactorv method is that devised by the author in 




Fig. 619. 

Fig. 617. — Diagram of femur showing the common sites of fracture of the femoral 
neck. {Surg., Gynecol, and Obstet., Feb. 1914.) 

Fig. 618. — Diagram showing the manner in which the cancellous tissue crushes when 
the neck is subjected to the displacing actiorf of the thigh and hip muscles, following 
operation with a simple screw or nail. {Surg., Gynecol, and Obstet., Feb., 1914.) 

Fig. 619. — Diagram showing the author's screw-plate in position. Angulation of 
the screw portion is prevented by the plate portion which secures a firm hold on the only 
available compact tissue in this region. {Surg., Gynecol, and Obstet., Feb., 1914.) 

which a modified Lane plate is employed, as shown in Fig. 619. 
By means of this screw-plate the compact tissue below^ the great 
trochanter is utilized to prevent the inner end of the screw portion 
of the appliance from being displaced downward. The head of the 
bone is thus hung on the end of the screw portion much as a hat 
is hung on a peg, the plate securing its hold on compact tissue. 



552 FRACTURES AND DISLOCATIONS 

Before drilling through the trochanter the surgeon should make 
sure of the proper alignment of the head and neck. This can 
usually be accomplished by dull dissection along the neck outside 
the capsule. Following operation, external fixation apparatus 
should be employed to relieve the bone of as much strain as pos- 
sible. Simple extension and counter-extension with the long side 
splint may be used, or the plaster cast applied. The cast is, as a 
rule, preferable following operation on the hip or thigh and should 
be applied before the patient comes out of the anesthetic. AVithin 
forty-eight hours of the operation a window should be cut through 
the plaster to expose the region of incision. In operating on the 
neck of the femur the parts may be exposed by a vertical incision 
over the trochanter or an incision of the U-type may be employed. 

The best time for operation is at the end of a week or ten days 
following the accident. "When the open method is selected early 
in the condition because it offers better reduction and apposition 
of the fractured surfaces the results are usually satisfactory. 
When, however, operation is performed as a last resort when other 
methods have resulted in non-union or deformity the results are 
not nearly as good. In operating for non-union the fibrous tissue 
must be cut away and the fractured surfaces freshened and secured 
in apposition, preferably by the screw-plate just described. This 
procedure necessarily results in some loss of tissue and shortening 
of the neck. If the fracture is through the inner end of the neck 
and the head is comminuted, it may be advisable to remove the 
fragments, round off the end of the femoral neck and rely on the 
formation of a new articular surface. Remarkably good results 
have followed resection of the femoral head. Murphy has demon- 
strated the possibility of making a new femoral head and articular 
surface from a transplanted portion of the great trochanter, and 
of reestablishing the function of the joint following ankylosis. 
These operations, however, are rarely called for as a result of frac- 
ture of the femoral neck. Operative intervention offers little in 
the aged and is seldom called for in children. It offers most in 
the healthy adult, and is indicated in cases in which good reduction 
cannot otherwise be obtained, and in instances in w^hich deformity 
or non-union with considerable loss of function has followed non- 
operative methods. 

After-Treatment. — The fact that the fragments have been placed 
in good apposition does not necessarily mean that they will remain 



FRACTURES OF UPPER END OF FEMUR 



553 



so and it should be the surgeon's greatest care during the after- 
treatment to see that the fixation apparatus employed is properly 
performing its function. Numerous adjustments will be needed 
during the process of repair. A weight of fifteen or twenty pounds 
may be necessary during the first few days but at the end of a 
week it may be entirely too much. If the patient is confined to 
bed the back and heels should be watched for signs of skin irrita- 
tion, and should they develop special care must be taken to keep 
the parts dry and relieved of pressure. The sheets should be clean, 
smooth and free from wrinkles and the patient should be frequently 




splint. 



620. — Diagrams illustrating the principles of tlie single and double Thomas hip 



sponged and rubbed with alcohol especially in regions subjected to 
pressure. If a metal splint or cast is used the points of pressure 
should be similarly watched and treated if irritation develops. If 
the cast is employed it may be necessary to cut a window in it, if 
the patient complains of persistent cutaneous pain in a given region. 
The duration of the after-treatment depends on the progress of 
repair at the seat of fracture. It may be impossible to secure bony 
union in the aged and fixation may, in some cases, be prolonged 
indefinitely without result. In this type of case it is better to get 
the patient up and about after sufficient time has elapsed to give 
the fragments a fair chance to unite. Function will, of course, be 



554 FRACTURES AND DISLOCATIONS 

imperfect but the patient will be better off than if a prolonged, 
futile immobilization is carried out. The older the patient the less 
the probability of bony union and the slower it will be in forming, 
if it does occur. In a middle aged person union should be well 
advanced at the end of eight or ten weeks but no weight should be 




Fig. 621. — "The Ambulatory Pneumatic Splint" with hip attachment. 

borne on the injured member inside of three months. During the 
first eight weeks the hip should be immobilized, after this period 
gentle passive motion is advisable up to the third month, though 
all strain should be guarded against. Because of the varying 
rapidity in the process of repair seen at different ages and the 
different types of fracture encountered, no hard and fast rule can 



FRACTURES OF UPPER END OF FEMUR 555 

be laid do^Yn regarding the length of fixation. The most reliable 
information concerning the progress of union is to be obtained 
through the X-ray. Rontgenograms taken at the end of, say, eight, 
ten, and twelve weeks will show the condition of the fragments 
and the progress of repair, and will constitute the very best guide 
in the resumption of function. The patient's comfort during the 
after-treatment deserves much consideration, especially in elderly 
persons. The surroundings should be as bright and cheerful as 
possible. His friends should visit him frequently but should not 
be encouraged to stay long enough to weary him. 

Prognosis. — Fracture of the neck of the femur is a serious injury 
even under the most favorable circumstances. In the aged it is 
particularly dangerous because of the low vitality of the patient. 
They not infrequently suffer greatly from shock and confinement 
and are subject to complications which, in their asthenic state, may 
produce death. Bony union has for years been considered as de- 
pendent on whether or not the fracture was within the joint cavity. 
The correct conditions, however, are probably whether or not the 
fractured surfaces are in firm apposition. 

Under proper treatment union is to be expected in a healthy 
adult but in the aged it may or may not be obtained regardless of 
the treatment followed. Fibrous union means some impairment of 
function, yet a surprisingly useful hip may result even when there 
has been failure in bony union and some deformity exists. 

The surgeon should never, even under seemingly favorable cir- 
cumstances, promise bony union. 

Injuries to the Feynoral Neck in Children. — The epiphysis of 
the head joins the neck at about the eighteenth year, and the bony 
tissue of the neck is tougher and less brittle than in adult or ad- 
vanced life. These anatomical variations account for the clinical 
picture accompanying injury of the femoral neck in childhood. A 
green-stick fracture of the neck of the femur or an epiphyseal sepa- 
ration of the head of the bone (incomplete as it usually is) is 
pathologically and mechanically quite different from fracture of 
the femoral neck as seen in the adult or the patient advanced in 
years. Accordingly the symptoms and course of the case are dif- 
ferent. In an incomplete fracture of the femoral neck the head of 
the bone is depressed and the neck approaches more nearly a right 
angle. This change in the angle of the neck increases the strain 
on it and further bending of the neck follows unless all weight- 



556 FRACTURES AND DISLOCATIONS 

bearing, jar and strain are removed. In ''starting" of tlie ep- 
iphysis the pathology is somewhat different, though the result is 
practically the same. When the epiphysis is "started" it is dis- 
placed downward, and the fractured surface is only partially con- 
tacted with the end of the diaphysis. This downward displacement 
of the head is equivalent to a downward bending of the neck seen in 
green-stick fractures of the neck, and if the patient continues to use 
the member the result will be the same ; namely coxa vara. Either 
of these injuries usually follows severe trauma and after being con- 
fined for a short time in bed the patient is up and about although 
limping. The limp is thought little of at first, but- when this 
symptom increases instead of improving the surgeon's advice is 
sought. In some instances apparent immediate recovery takes 




Fig. 622. — Diagrams to illustrate the development of coxa vara in a child following 
an injury to the hip in which the epiphysis is "started." A., normal hip in child about 
four years old. B., same after injury which has started the epiphysis of the head and 
allows the trochanter to be displaced upward. C. change in angle of neck resulting 
from the altered position of the head. D., further change in the angle of the neck and 
raising of the trochanter, which result from the increased strain on the neck of the 
femur as it approaches the right angle. The elevation of the trochanter limits abduction 
bv mechanical interference between the trochanter and the rim of the acetabulum. 
(After Whitman.) 

place, and months or even years later coxa vara develops with pro- 
gressive bending of the femoral neck and corresponding impairment 
of function. The immediate symptoms are slight, as a rule, and the 
condition may go unrecognized by the surgeon as well as the family. 
The apparent insignificance of the initial injury and the disastrous 
late consequences point out the necessity of the most careful ex- 
amination following injuries of the hip in children. If the lower 
extremities are carefully measured it will usually be found that the 
injured member is from one half to one inch shorter than its fellow, 
and there may be slight eversion of the thigh. The X-ray should be 
employed when there is a history of injury to the hip, even if only 
for the purpose of exclusion. 

If the case is seen soon after the initial injury it should be treated 
by rest in bed with Buck 's extension applied and sand bags about the 



FRACTURES OF UPPER END OF FEMUR 557 

injured member, or the long side splint employed. If deformity 
exists after the acute traumatic stage has passed the plaster cast 
should be employed with the lower extremity in abduction accord- 
ing to the principles laid down by Whitman. (See Fig. 614.) At 
the end of a month this dressing may be replaced by an ambulatory 
hip splint with traction which is to be worn for a number of months, 
until union is solid and the danger of coxa vara passed. After this 
splint is removed the hip should be frequently examined by the 
X-ray to determine whether the strain incurred by use of the mem- 
ber is causing any change in the angle of the neck. If such is 
found to be the case the splint should be resumed with increased 
traction. If the case is seen only after the development of the 
secondary symptoms and coxa vara is present the traction am- 
bulatory splint should be employed and worn for a number of 
months. If the deformity and disturbance in function are pro- 
nounced it is well to consider the advisability of an osteotomy to 
restore the angle of the neck. 



CHAPTER XXXVIII. 

FRACTURES OF THE FEMORAL SHAFT. 

Surgical Anatomy. — The shaft of the femur consists of a tube 
of heavy compact tissue which is capable of withstanding greater 
strain than the shafts of other long bones. The, diameter of the 
shaft grows larger and the compact tissue thinner as the extremi- 
ties are approached. Ossification spreads from a single center 
which makes its appearance about the seventh week of foetal life. 
The shaft is slightly curved with the concavity backward. The 
linea aspera serves to strengthen the concave posterior aspect and 
affords attachment to the adductor muscles. In the upper third of 
the shaft this line divides into three ridges, while in the lower 
third of the bone it bifurcates to form the supracondylar ridges. 
The femoral vessels cross the internal supracondj^lar ridge under a 
fibrous arch in the adductor magnus and become the popliteal ves- 
sels. From the point where the artery pierces the adductor mag- 
nus to the knee joint, it lies in close relation to the posterior surface 
of the bone, and in fractures of this region the vessel may be 
injured by a displaced fragment. The nerve and vein lie more 
superficially in the popliteal space and are less subject to injury 
from the bone, than is the artery. The greater part of the three 
surfaces of the femoral shaft are taken up by the attachments of 
the three vasti muscles which, together with the rectus, make up 
the quadriceps extensor. Fracture of the shaft of the femur is 
usually attended by great shortening, which results from the con- 
traction of the powerful thigh muscles. The manner in which the 
fragments override will depend largely on the direction and nature 
of the break. In fractures of the upper third of the shaft, it is 
common to see the upper fragment displaced outward or outward 
and forward, while the lower fragment is drawn upward by the 
thigh muscles and displaced inward by the action of the adductor 
group. Outward rotation of the upper fragment not infrequently 
results from the pull of the ilio-psoas. A transverse fracture with 
the serrated surfaces engaged will, of course, allow only of angular 

558 



FRACTURES OF THE FEMORAL SHAFT 



559 



deformity as long as the fractured surfaces remain locked, but this 
condition is rare. Fractures in the lower third of the shaft are 




Figs. 623 and 624. — Anterior and posterior surfaces of the right femvir with at- 
tached muscles. Ob. c6 G., Obturator internus and gemelli ; P., Pyriformis; G.Min., 
Gluteus minimus; V.E., Vastus externus ; G.Med., Gluteus medius;' Q.F., Quadratus 
femoris; Ps., Psoas; Pe., Pectineus ; /., Uiacus ; A.B., Adductor brevis ; A.M., Adductor 
magnus; V.I., Vastus internus; A.L., Adductor longus ; C, Crureus or Vastus inter- 
medius; Bic, Biceps; S.G., Subcrureus ; G., Gastrocnemius; PL, Plantaris. 

often accompanied by a backward displacement of the lower frag- 
ment as a result of the action of the gastrocnemius, the two heads 
of which are attached just above the condyles on the posterior 



560 



FRACTURES AND DISLOCATIONS 



aspect of the bone. The powerful action of the thigh muscles 
usually results in pronounced deformity and their bulk renders 
palpation difficult. 

Etiology. — Fractures of the femoral shaft constitute less than 
three percent of all fractures. Approximately one-fifth of the 
fractures of the femoral shaft occur in the upper third (not in- 
cluding the femoral neck), three-fifths occur in the middle third 




Fig. 625. — Transverse fracture of the shaft of the femur with overriding and angular 
deformity. 

of the bone, vrhile one-fifth is seen in the lower end. Fracture of 
the femoral shaft is the result of violence, direct and indirect and 
of muscular action, although the latter cause is probably never 
responsible for fracture in a healthy bone. Twisting strains fre- 
quently produce the spiral or oblique fracture so commonly seen 
in the upper and middle thirds of the shaft, while direct violence 
more often results in transverse fracture of the lower third. All 



FRACTURES OF THE FEMORAL SHAFT 



561 



types of fracture, however, may be seen in any portion of the 
siiaft. 

Symptoms. — Immediate and total loss of function is seen fol- 
lowing the accident, except in the green-stick type occurring in 
children. Pain is usually pronounced and the deformity is char- 
acteristic. The limb below the break is rolled, either inward or 




Fig. 626. — Fi-acture of right femur about twenty minutes after injury. Fracture 
caused by patient falling from first floor fire escape to the sidewalk. Violence trans- 
mitted through foot and leg. Note the shortening of the limb, the eversion of the foot 
and knee and the twisting of the muscles of the thigh. 




Fig. 627. — Case similar to the preceding alxmt thiH'e and one-half months after 
injury. Fibrous union, deformity, loss of function. Fracture slightly oblique and about 
four inches below the great trochanter. Note the eversion, shortening, and wasting of 
the thigh muscles. Upper end of lower fragment is in contact with the lower surface 
of the femoral neck and united to it by fibrous tissue. Upper fragment abducted. Case 
operated. Incision on outer side of thigh, dense fibrous tissue broken up, ends of bone 
squared and wired together, most of the shortening and all of the eversion corrected. 
Function restored. Case first seen by author three and a half months after injury. 



outward (usually the latter), and the helplessness of the condition 
is typical. There is often considerable swelling at the site of frac- 
ture and in addition the thigh is actually thickened as a result of 
the overriding fragments and shortened muscles. The thigh is 
shortened according to the distance the fragments have overridden. 
The decrease in the length of the thigh can, as a rule, be recognized 



562 



FRACTURES AND DISLOCATIONS 



without the aid of the steel tape. Pain is greatly increased on 
manipulation. Abnormal mobilit.y can usually be recognized as 
soon as the lower extremity is grasped and moved. Crepitus may 
be elicited if the fractured surfaces are in contact. The symptoms 
are, as a rule, pronounced and the shock considerable. Spasm of 
the thigh muscles is present and the resulting shortening usually 




Fig. 628. — Fracture of left femur about one hour following injury. Lower end of 
upper fragment produces the prominence on the outer aspect of the thigh as indicated 
by the arrow. Patient assumes this position as a matter of choice. Leg much short- 
ened though this is difficult to determine in the picture as the opposite thigh is flexed. 




Fig. 629. — Fracture nt tlie ^haft of the femur at point indicated by arrow. Pro- 
nounced shortening with thickening of thigh at seat of fracture as a result of over- 
riding of fragments. Complete eversion below break. Flail-like condition recognized 
when the limb is manipulated. Upper fragment displaced anteriorly. Photograph taken 
-within twenty minutes of injury. 



increases during the first twenty-four or forty-eight hours, unless 
special preventive measures are employed in the treatment. 
Green-stick fracture sometimes occurs in children. In the pres- 
ence of this condition the symptoms will be less pronounced, bowing 
of the femur will usually be apparent and lateral pressure on the 
thigh, in the direction of the bowing, will show an increased spring 
in the bone as compared with the uninjured femur. 

Diagnosis. — There is seldom any difficulty in recognizing fracture 
of the femoral shaft. The deformity, shortening, loss of function, 
abnormal mobility and crepitus render the diagnosis easy. The 
exact nature and position of the fracture, however, can only be 



FRACTURES OF THE FEMORAL SHAFT 563 

learned by means of the X-ray or during operation when the frag- 
ments are exposed. Even under anesthesia, palpation and manip- 
ulation atford only an imperfect knowledge of the nature of tlie 
fracture. Fracture of the upper end of the femoral shaft might 
be confounded with fracture of the femoral neck, fracture of the 
rim of the acetabulum or fracture of the pelvis. The unaltered 
position of the great trochanter, its normal relation with Nelaton's 
line (see page 533) and the fact that it fails to rotate with the shaft, 
will serve to difterentiate fracture of the femoral shaft from the 
conditions just enumerated. Fracture of the shaft of the femur in 
the new-born is devoid of subjective symptoms and must be recog- 
nized by the physical signs. 

The less the thigh is manipulated the better : nearly all that can 
be learned by physical examination can be gathered by inspection 
alone, if the surgeon is observant. The deformity, helpless attitude 
of the limb, shortening, etc., and the history of the case should be 
sufficient evidence of the presence of fracture and its approximate 
location. Abnormal mobilit}^ and crepitus manifest themselves 
while the limb is being brought back into alignment incident to the 
application of Buck's extension and splints. 

If doubt exists, careful measurements of the two lower extrem- 
ities should be made and the same precautions are to be observed 
as already cited in fracture of the neck of the femur (page 539). 
The patient should lie straight in bed so that a line drawn through 
the two antero-superior iliac spines is at right angles to the median 
plane of the body and the lower extremities should be parallel. 
The usual deformity, however, with the lower extremity rolled out- 
ward, the thigh thickened and shortened and often angular dis- 
placement present, is, as a rule, too pronounced to require mensura- 
tion to establish a diagnosis. Moreover it will be most unwise to 
manipulate the thigh to bring it to a position which is parallel or 
symmetrical to its fellow, simply for the purpose of mensuration 
when the condition is already apparent through inspection alone. 

Treatment. — The treatment of fracture of the femoral shaft varies 
with the age and condition of the patient and the nature and 
position of the fracture. The emergency treatment and the care 
of the case during the first week are practically the same in all 
instances and will be considered first. 

The emergency treatment of these fractures is of importance 
in transporting the case from the scene of the accident to the 



564 



FRACTURES AND DISLOCATIONS 



hospital or home. Hospital facilities and surroundings are of the 
greatest advantage in the proper treatment of fractures of the thigh 
and the patient should be advised of this fact at the earliest possible 
moment. In transporting the j)atient the thigh and leg should be 




Fig. 630. — Diagram illustrating the manner in which lateral traction may be applied 
to bring the fragments into better position. The appliances used in the treatment of 
fractures of the femoral shaft are similar to those employed in the treatment of frac- 
tures of the upper end of this bone. (See Figs. 606 to 612.) 

supported by some form of temporary splint to prevent further 
laceration of the soft tissues by the fragments. This may be accom- 
plished by means of a bed slat or some other similar piece of wood 




Fig. 631. — Adjustable inclined plane used in the treatment of certain fractures of 
the femur. For other methods of fixing the thigh in various degrees of flexion see Figs. 
615, 632, 633, 650, 651, 652, 653, 654 and 706. 

which is bound or strapped to the lower extremity and trunk on 
the injured side. A blanket, sheet or towels may be used to secure 
the splint in position. A short splint on the inner side of the thigh 
will increase the security of the dressing. A satisfactory emergency 



FRACTURES OF THE FEMORAL SHAFT 



565 



splint may be made with broomsticks and a blanket. In moving 
the patient to or from the stretcher one person should confine his 
entire attention to the injured member to prevent motion between 
the fragments, while assistants raise and move him. As soon as 




Figs. 632 and 633. — Showing the method of treating fracture of the shaft of the 
femur m children by vertical extension. At the end of two Aveeks the extremity is low- 
ered to an inclined plane and treated in this position until union is complete. The pa- 
tient IS secured to a Bradford frame by means of a band about the body. 



45 



uiuimnm^Hm 




iiiiiii)»ini.iiii]ij)i))i;ii))»)»|i|) 




^^S 


1 — — ^ ^-i=— - 


1 1 1 — 1 


! 




1 1 - 






1 


Zj -f^=— 


L ■■! r 






1 


1 ~. ■ - 


















— MJ^ 


















H 


1 








' 






—^ 









• n»ttimi»»>'>ili)ii>i»iiii))ii)i>iiiii>>niiiiiiii'iiiiii 




Fig. 634. — The Bradford frame. The frame is made of gas pipe and covered with 
canvas It is usually necessary to employ some means of securing the patient (especially 
a child) to the frame. (See Fig. 632.) >= f \ f .y 

the patient is placed in bed a Buck's extension apparatus should be 
applied to control the spasm in the thigh muscles. Coaptation 
splints and a long side or T-splint should be employed in prepara- 
tion for the first week's treatment, during which time the traumatic 
reaction is to take place. 



566 FRACTURES AND DISLOCATIONS 

During the first week or ten days the usual case of simple fracture 
of the thigh is treated by means of Buck's extension, coaptation 
splints and the long side splint. Buck's extension and the long 
side or T-splint have already been described under the treatment 
of fractures of the femoral neck. Coaptation splints are short, 
light splints surrounding the thigh at the seat of fracture and are 
often misused with the idea of forcing the fragments together by 
means of lateral pressure. They serve a purpose in the treatment 
of these cases but their value has been greatly overestimated. They 
are fairly efficient in maintaining reduction after it has been accom- 
plished but have little or no effect in forcing displaced fragments 
back into position. If applied too tightly they are capable of doing 
considerable harm by interfering with the circulation or by forcing 
the muscles against sharp fragments. The coaptation splints should 
be well padded and are best held in position by means of circular 
strips of adhesive plaster. 

All the materials for the application of Buck 's extension, together 
with the side splint and coaptation splints should be at hand and 
ready for use before the parts are disturbed. It will usually be 
best to have the patient anesthetized to relax the muscles. The 
thigh should be brought back into alignment with as little manipu- 
lation as possible. An attempt at accurate apposition of the frac- 
tured surfaces should be made at this time, yet reduction immedi- 
ately following the accident is usually only partially successful. 
This is because most fractures of the shaft are oblique or spiral, and 
although anesthesia relaxes the muscles, yet when the patient 
regains consciousness the spasm is almost sure to again displace the 
fragments, even though heavy extension is employed. As a rule the 
best that can be expected at this time will be an approximate 
reposition. Proper reduction can best be accomplished at the end 
of four or five days, or a week, when the extension apparatus has so 
exhausted the muscles that the displacing strain, resulting from 
local spasm, is practically negligible, when guarded by a heavy 
weight at the end of the extension cord. An accurate knowledge 
of the nature and position of the fracture is most valuable in 
attempting a permanent reduction, and for this reason an X-ray 
plate should be taken soon after the accident. By a study of the 
Rontgenogram and the symptoms of the case we are able to deter- 
mine whether ordinary treatment will give good results or whether 
operative intervention will be necessary to accomplish and main- 



FRACTURES OF THE FEMORAL SHAFT 567 

tain good reduction. In a simple transverse fracture it will often 
be possible to secure a satisfactory engagement without operation, 
but when the fracture is spiral or oblique, as is so frequently the 
case, it will usually be necessary to resort to the open method to 
obtain the best results. Non-operative treatment is reserved for 
those rare cases in which good reduction can be accomplished and 
maintained by manipulation and traction and immobilization, and in 
cases in which operation is contraindicated on constitutional 
grounds. If good reduction is possible without operation the case 
may be treated, until union takes place, with the apparatus just 
described : namely Buck 's extension, coaptation splints and the long 
side .splint or the T-splint. After the traumatic reaction has sub- 
sided the cast may be employed instead of the above apparatus. 
The cast is usually applied with the lower extremity in the 
straight, extended position, but if the surgeon finds that some other 
position is more favorable to the retention of the fragments, he 
should employ whatever attitude is thus shown to be best adapted 
to the needs of the case. In any event the cast should extend from 
the waist to the foot and should be lined with sheet cotton to 
prevent irritation. The upper portion of the cast secures a firm 
hold on the pelvis while the lower portion immobilizes the thigh 
and leg. 

In fractures of the upper third of the shaft the upper fragment 
frequently shows a tendency to outward, or outward and forward, 
displacement and accordingly moderate flexion, or flexion with 
abduction, is often found to be the position favoring retention. 
This may be obtained by means of the double inclined plane, with 
extension from the knee in the line of the axis of the femoral shaft, 
or a cast may be applied with the hip slightly flexed, or flexed 
and abducted, with a corresponding position of flexion at the 
knee. 

In fractures in the lower third of the bone the lower fragment is 
often displaced backward by the action of the gastrocnemius, and 
when this occurs, flexion at the knee is the position in which the 
condition should be treated and the double inclined plane, or cast 
in flexion, are the appliances used. ( See Chapter XXXIX, ' ' Frac- 
tures of the Lower End of the Femur.") 

These attitudes of fixation may favor the retention of fragments 
but are seldom really efficient in accomplishing good results. The 
fact that these positions are needed to favor reduction and retention 



568 FRACTURES AND DISLOCATIONS 

usually means that the case should be subjected to operation to 
accomplish really good apposition. 

In children under ten years of age, fractures of the femoral 
shaft are best treated by vertical suspension of the lower extremity, 
while the child rests on a Bradford frame in the recumbent position. 
A Buck's extension apparatus is applied as already described in 
the treatment of fractures of the hip, with this exception, the line 
of extension is vertical instead of horizontal. The cord passes 
through a pulley directly over the middle of the bed and on a 
vertical line with the hip. The lower extremity is thus maintained 
in a position perpendicular to the trunk. It is best to have the 
child secured to a Bradford frame, which greatly facilitates the 
after-care of the case and prevents the patient from moving about 
to the extent of disturbing the fixation. This position of vertical 
extension is maintained for about two weeks, after which the lower 
extremity is lowered to an inclined plane (about 40 degrees), and 
extension kept up in this position for another week. A plaster 
spica of the pelvis and lower extremity, or a hip brace, may then 
be applied and the patient allowed up and about with the aid of 
crutches and a high sole on the shoe of the opposite foot. The thigh 
should not be subjected to strain until the surgeon is sure of solid 
union, otherwise a bowing deformity may result. (See Fig. 632.) 

Fractures of the thigh in patients advanced in years present some 
of the same problems already described under the treatment of 
fractures of the hip in the aged (see page 547). Hypostatic 
pneumonia or bedsores and other complications may develop if the 
patient is long confined to bed. Accordingly some form of ambu- 
latory treatment should be adopted as soon as the shock and 
traumatic reaction have subsided. The Thomas hip splint, plaster 
cast, or "ambulatory pneumatic splint" with hip attachment ma}^ 
be used in getting the patient on his feet. In very old and feeble 
persons it is often best to employ the cast (see page 548) with the 
thigh and knee flexed so that they may sit in a chair during the 
day and rest in bed at night. 

In fractures of the femoral shaft in the new-born the thigh is 
best treated in complete flexion, being bound to the trunk in this 
position. The foetal attitude is thus taken advantage of to secure 
immobilization. The thigh and abdomen are previously dried and 
powdered and a few layers of soft linen placed between them, 
before the thigh is fixed. 



FRACTURES OF THE FEMORAL SHAFT 



569 



In fractures of the lower third with backward displacement of 
the lower fragment the double incline plane may be used instead of 
the plaster cast and is much more appropriate in the early part of 
the after-treatment, during the time the acute traumatic inflamma- 
tion is at its height. 

Operative Treatment. — A large proportion of fractures of the 
femoral shaft demand operative intervention if the best possible 
results are to be obtained. Fractures of the upper and middle 
thirds are usually of the spiral or oblique type and nothing, as a 
rule, will secure the fragments in accurate apposition except direct 
fixation following open reduction. In the lower third of the shaft 
it is more often possible to secure good reduction by non-operative 
treatment, yet fracture in this region often demands the open 
method. The shaft of the bone is usually best exposed through a 
longitudinal incision on the outer aspect of the thigh in the region 
of the fracture. AVith the fragments exposed, strong traction is 
made on the lower extremity and the serrated surfaces fitted 




Fig. 635. — The Nichols frame. An appliance of great advantage in operating on 
fractures of the femoral shaft. A steady and powerful traction is maintained on the 
limb during the operation. 



together. They are then secured by means of wire or a heavy Lane 
plate. The Nichols extension frame is one of a number of appli- 
ances which are of value in exerting traction and countertraction 
during operation (see Fig. 635). Nowhere in the body is internal 
fixation subjected to greater stress than here in the shaft of the 
femur, and the material used should be strong enough to serve the 
purpose, pending the formation of bony callus. A good example of 
the fixation of a double spiral fracture of the middle of the femoral 
shaft with wire is shown in Figs. 636 and 637. When wire is 
employed two points of fixation should be had to secure the proper 
leverage and to prevent angular deformity. If the wire is passed 
circularly about the shaft it will often accomplish as much as if it 
were passed through drill holes in the bone. In encircling the shaft 



570 FRACTURES AND DISLOCATIONS 

the instrument carrying the wire should hug the bone closely to 
avoid injuring the femoral artery or one of its perforating branches 
which, in the middle third of the shaft, lie in close relation with the 
internal border of the bone. If a Lane plate is used it should be 
heavy and long, preferably of the Sherman-Pierce type, and should 
be provided with six screw holes. When the fixation is completed 



Fig. 636. — Double spiral fracture of femur with uuattached fra2:ment. X-ray p.ate 
taken after everything in a non-operative way had been done to accomplish reduc- 
tion. 

Fig. 637. — Same ca&e after operation. Fragments in accurate apposition with the 
result that the lower extremity shows no shortening. 

the thigh should be raised from the table and in this position it 
should be capable of sustaining the weight of the leg without giv- 
ing. The muscles should be brought together with a running 
suture of catgut and the skin closed with silk-worm gut or horse 
hair. A plaster cast should then be applied, after proper dressings 
have been placed on the wound and the lower extremity covered 



FRACTURES OF THE FEMORAL SHAFT 



571 



with sheet cotton. The cast should extend from the waist to the 
foot, leaving- the toes exposed, so that the condition of the circula- 
tion in the extremity may be watched during the after-treatment. 
Twenty-four to forty-eight hours following the operation a window 
should be cut in the cast, the wound inspected and gentle pressure 




Fig. G38. 




Fia-. 639 



Fig. 638. — Same case two years following operation. Perfect restoration of func- 
tion. 

Fig. 639. — Same case six years aft«r operation. Note the condition of the callus 
and wires, also the reopening of the medullary canal. 



made to express any dead blood which may have collected in the 
wound. 

In compound fractures of the thigh operative intervention is 
practically always indicated. The wound should be enlarged if 
necessary and all devitalized tissue trimmed away. When this 
has been done the wound should be washed with a few gallons of 
sterile salt solution and the muscles and skin accurately approx- 



572 FRACTURES AND DISLOCATIONS 

imated (see "Treatment of Compound Fractures," page 789). 

After-Treatment. — The duration of the after-treatment varies 
considerably with the accuracy of apposition and the age of the 
patient. Union will therefore take longer in non-operated cases 
than in cases which have been subjected to the open method (see 
"OperatiA^e Treatment of Fractures," page 754). In a healthy 
adult, union will usually have taken place in from six weeks to two 
months, although refracture may easil}^ occur at this time if the 
limb is subjected to any considerable strain. In children union 
can usually be expected in from four to six weeks. In the aged 
union may be very much delayed and in some cases it may be 
impossible to obtain bony union at all. No matter w^hat line of 
treatment is followed the case should receive the most careful atten- 
tion during the after-treatment. The patient should be seen daily 
for the first few weeks. If tlie fracture is treated by extension and 
splints, frequent adjustments will be necessary to keep the patient 
comfortable and to maintain the fragments in proper position. 
During the first few days the weight should be heavy (usually about 
twenty-five pounds in the adult) to control the spasm in the thigh 
muscles which, at this time, is at its height. The weight should be 
gradually diminished as the muscles become exhausted and the 
spasm less active. Frequent measurements of the lower extremity 
should be made to determine the extent of the shortening and the 
influence of the extension apparatus in overcoming it. If the cast 
or ambulatory splint is used it will require adjustment from time 
to time and the parts with which it comes in contact should be care- 
fully^ watched for evidences of irritation. If, during the time the 
cast is being worn, the patient complains of persistent irritation in 
a given place, a window should be made to determine the condition 
of the skin or to treat a sore if one has developed. Following oper- 
ative intervention the temperature chart should be w^atched for 
evidences of infection and the wound should be inspected within 
the first few days. Infection need not be expected, however, if the 
proper surgical technique has been followed out. 

If ambulatory treatment is not employed it is usually best to keep 
the patient in bed for a week or so following the removal of the 
splints. During this time massage and passive motion should be 
instituted. When the patient is first allowed up no weight should 
be borne on the injured member until he is thoroughly adept with 
the crutches. The thigh should be inspected daily during the time 



FRACTURES OF THE FEMORAL SHAFT 573 

he is beginning to bear weight on it and if the slightest evidences 
of bowing develop he should be again placed in bed and extension 
apparatus applied. It is advisable at this time to have an X-ray 
plate made to determine the condition of the callus. 

Prognosis. — Fracture of the femoral shaft is always a serious 
accident and the prognosis should be guarded. In unoperated cases 
shortening is the rule and angular or rotary deformity is not 
uncommon. If the shortening is less than an inch or an inch and a 
half, and the general alignment of the shaft is not changed, the 
result is said to be good. If the shortening is not greater than an 
inch and a half the tipping of the pelvis will compensate for the 
deficiency in the length of the lower extremity so that walking will 
be practically normal. Pain and weakness in the injured thigh 
are common following fracture of the femoral shaft and often 
persist for years. Little can be done to alleviate them. The more 
perfect the reduction the more complete and prompt will be the 
restoration of function. The results following the open treatment 
with internal fixation of the fragments are decidedly better than 
those following the non-operative method. It is often possible to 
secure union without shortening, even in spiral fractures, if 
recourse is had to operative intervention. 

If infection follows a compound fracture the outlook is often 
serious. With free drainage of the parts the danger is greatly 
reduced and bony union may follow. 



CHAPTER XXXIX. 

FRACTURES OF THE LOADER END OF THE FEMUR. 

Under this heading are included the various fractures occurring 
in the lower end of the bone, some of which enter the joint cavity 
of the knee. Separation of the lower femoral epiphysis is also con- 
sidered under this heading instead of being taken up separately as 
is customary. 

Surgical Anatomy. — The lateral surfaces of the large expanded 
lower extremity of the femur are subcutaneous and can be palpated 
without difficulty. With the knee flexed the upper margin of the 
trochlear surface may be felt anteriorly. The two heads of the 
gastrocnemius are attached posteriorly just above the condyles. To 
the external surface of the outer condyle (outer tuberosity) is 
attached the tendon of the popliteus, and at the lower end of the 
external supracondylar ridge is the origin of the plantaris. In 
the notch between the condyles are attached the upper ends of the 
crucial ligaments. The popliteal artery lies in close relation with 
the posterior surface of the bone, from the point where it crosses 
the internal supracondylar ridge to the bottom of the intercondyloid 
notch. It may be injured in this position when fracture of the 
lower end of the bone occurs. The vessel is more often temporarily 
compressed than permanently injured, which fact accentuates the 
importance of early reduction. The popliteal nerve and vein lie 
more superficially than the artery, and accordingly are much less 
frequently injured by displaced fragments. 

The most common fracture of the lower end of the femur is trans- 
verse and a short distance above the condyles. Occasionally the 
lower fragment is split vertically, thus producing the typical T- or 
Y-fracture which enters the joint cavity. A more severe type of 
T-fracture is one in which the lower end of the shaft is driven into 
the lower fragment with considerable comminution and a vertical 
splitting into the intercondyloid notch. If it were not for the inter- 
condyloid notch the T-fracture would probably not occur. 

Either condyle may be broken off from the remainder of the bone. 

574 



FRACTURES OF LOWER END OF FEMUR 575 

AVlieu force is applied to the knee in a lateral direction or when 
violence is transmitted longitudinally through the leg, the tuber- 
osities of the tibia play an important part in the pressure they may 
exert against the condyles of the femur. In like manner the pull 
of the lateral ligaments may result in fracture of a condyle when 




Fig. 641. 



Fig. 640. — Lateral view of the lower end of tlie femur. 
Fig. 641. — Coronal section of the lower end of the femur. 

the knee is subjected to lateral angular displacement. It is more 
common for the lateral ligaments to tear away only their bony 
attachments on the femoral tuberosities. This condition is usually 
represented by a portion of the surface compact tissue, together 
with some of the underlying cancellous bone, remaining attached to 



576 



FRACTURES AND DISLOCATIONS 



the ligament which is torn away and displaced from the tuberosity. 
This type of fracture is more properly a complication of subluxa- 
tions or ' ' sprains ' ' of the knee, and will be considered under ' ' Dis- 
locations of the Knee," page 613. 

The epiphyseal cartilage corresponds roughly to a horizontal 
plane passing just above the condyles and through the adductor 
tubercle. The top of the trochlear surface just touches this plane. 
The lower femoral epiphj^sis is ossified from a center which makes 




Fig. 642. — Rontgenogram of the knee showing the locations of the epiphyseal car- 
tilages. 



its appearance shortly after birth. Epiphyseal separations cannot 
occur after the twentieth year since the epiphysis joins the shaft 
at this time. In fact they are rare after the sixteenth year. 

The injuries, then, to which the lower end of the femur is subject 
are: supracondylar fracture, T-fracture, fracture of either condyle 
separating it from the remainder of the bone, epiphyseal separa- 
tion and avulsion of a portion of the surface of a tuberosity by the 
pull of the ligaments. In rare instances we may see a longitudinal 
splitting of the lower end of the shaft which extends through the 



FRACTURES OF LOWER END OF FEMUR 



577 






Fig. 644. 

Fig. 643. — Fracture of the lower end of femur with angular deformity and crush- 
ing of cancellous tissue in the lower fragment. 

Fig. 644. — Supracondylar fracture Avith pronounced overriding deformity. 




ig. 645. 



Fig. 646. 



Fig. 645. — Old displaced fracture with refracture through callus 
Fig. 646. — Fracture of femur with lateral overriding deformity. 



578 



FRACTURES AND DISLOCATIONS 



lower end of the bone into tlie joint cavity. In some cases we may 
see a portion of the surface of the tuberosity driven inward by 
severe violence confined to a small area. 

Symptoms. — The symptoms vary with the age of the patient and 
the severity and nature of the injury. In supracondylar fracture, 
fracture of one of the condyles or epiphyseal separation, the loss of 
function is complete. The patient is unable to stand on the injured 
member or to raise the foot from the bed. Deformity is usually 
present and varies with the position of the fracture. In the simple 
supracondylar type the lower fragment may be displaced in any 




Fig. 647. — Fracture of the lower third of the femoral shaft. Note the shortening, 
external rotation and thickening of the thigh. Lower fragment displaced posteriorly. 
Case first seen twent>-foar hours after injury at which time this photograph was taken. 




Fig. 648. — Compound comminuted fracture of the lower end of the femur. The 
lower end of the upper fragment is displaced anterioi"ly and has penetrated the skin. 
The resulting wound shows black in the photograph and blood is seen trickling down 
the side of the knee. 



direction. If it is free to move (if not obstructed by the lower end 
of the upper fragment) the action of the gastrocnemius will tend 
to displace it backward. In any type of fracture of the lower end of 
the femur it is more common to see the lower end of the upper 
fragment displaced forward and downward- while -the lower frag- 
ment is displaced backward. In epiphyseal separations the reverse 
is usually true, the epiphysis is displaced forward and upward, in 
front of the lower end of the diaphysis. In T-fracture or fracture 



FRACTURES OF LOWER END OF FEMUR 579 

of one of the condyles the transverse diameter of the lower end of 
the femur is usually increased. Injury to the popliteal artery may 
occur in any of these fractures of the lower end of the femur, 
especially in epiphyseal separations, and the resulting symptoms 
of disturbed or destroyed circulation will depend on whether or not 
the artery has been compressed or lacerated. In fractures of the 
lower end of the femur it is not uncommon to see the lower end of 
the upper fragment projecting" through the skin above the patella. 
In epiphyseal separations the condition is often rendered compound 
by the lower end of the diaphysis projecting through the skin cov- 
ering the popliteal space. 

Abnormal mobility is regularly present but the proximity of the 
knee joint renders this symptom at times difficult to recognize. In 
fracture of one of the condyles or in T-fracture the loss of lateral 
stability in the knee is usually pronounced. Crepitus may be 
elicited unless the fragments have overridden so that their serrated 
surfaces are no longer in contact. In epiphyseal separations the 
epiphj^sis is, as a rule, displaced anteriorly and upward and 
crepitus cannot be elicited until the fractured surfaces are brought 
back into contact and even then it is soft and cartilaginous rather 
than bony. 

Diagnosis. — If the case is seen early before the onset of swelling, 
it will usually not be difficult to recognize the nature of the injury. 
There is, as a rule, disturbance in the alignment of the bones of 
the thigh and leg which can be determined by inspection. Short- 
ening of the thigh is the rule since the fragments so frequently 
override. Fracture in this region without deformity is the excep- 
tion. Abnormal mobility is usually characteristic. The lateral 
stability of the knee is impaired, especially when the lower fragment 
is divided into two or more pieces. Where the swelling is great it 
may be difficult to determine whether the fracture is in the lower 
end of the femur or the upper end of the tibia. 

The deformity in these fractures is variable, though the most 
common displacement is backward in the lower fragment. In 
epiphyseal separations the deformity is more uniform wdth the' 
epiphysis displaced upward and forward. This condition is most 
commonly seen about the tenth or twelfth year and the crepitus 
elicited is soft and cartilaginous rather than bony. 

All unnecessary manipulation for diagnostic purposes should be 
avoided because of the liability of injury to vessels and nerves. 



580 



FRACTURES AND DISLOCATIONS 



The manipulations incident to reduction will afford as much 
information to the surgeon as those conducted simply to establish a 
diagnosis. When the X-ray is available the most complete informa- 
tion concerning the fracture may be gained without disturbing the 
parts. 

Treatment. — Anesthesia is essential in reducing fractures of the 
lower end of the femur. AYith a simi)le supracondylar fracture 
reduction should be accomplished as soon as possible and the frag- 
ments immobilized in splints. Difficulty is sometimes experienced 
in bringing the fractured surfaces back into apposition and w^hen 
such is the case we should resort to operative intervention. The 



A 




Fig. 649. — Cabot posterior Avire, hip splint 



Wire bent to make splint. B. 



Side view showing bends to conform to the posterior surface of the lower extremity and 



^ _ aiorm to lue posierior suriace oi me lower exire 

hips, with knee in a position of slight flexion. C, Splint covered and lateral 
tached to encircle the trunk. 




-^ 



650. — Cabot posterior wire splint bent to be used as double inclined plane. 



fact that the popliteal artery may be injured during reduction 
should never be lost sight of and accordingly manipulations should 
be most guarded. If reduction cannot be accomplished by traction 
and manipulation, the open method should be instituted at once, 
especially if there is the slightest indication that the popliteal artery 
is being compressed. In manipulating the fragments pressure 
should never be made in the popliteal space lest the artery be driven 



FRACTURES OF LOWER END OF FEMUR 



581 



against the end of one of the fragments. Pressure to force the lower 
end of the upper fragment forward should be made in the middle 
of the thigh posteriorly, where there will be no danger of injury to 
important soft tissues. In the presence of a T-fracture or a frac- 
ture of one of the condyles, an attempt should be made to force the 




Fig. 651. — Du]>in's adjiistable splint used as a doulde iiudinod jdane in a case of 
fracture of the femur. Extension in the long axis of the femur is employed to maintain 
reduction. 




Fig. 652. — Dupuy's adjustable metal splint for the treatment of fractures of the 
lower extremity. 

condyles together as reduction is being accomplished. This is an 
important matter since separation of the femoral condyles means 
loss of proper alignment between the femoral and tibial articular 
surfaces with subsequent disturbance in the function of the knee 
joint. If the fracture is near the knee and the lower end of the 
upper fragment is displaced forward the prominence thus produced 



582 



FRACTURES AND DISLOCATIONS 



may interfere with the action of the patella and quadriceps after 
union has taken place. 

In separation of the epiphj^sis reduction should be accomplished 
at once and with the least possible manipulation. Gradual flexion 




Fig. 653. — Adjustable doulole inclined plane, fracture box. 

of the knee while pressure is being exerted on f he epiphysis will 
aid materially in effecting reduction. If reduction cannot be ef- 
fected by traction, counter-traction, flexion and direct pressure on 
the epiphysis, it should be accomplished by operative intervention. 




Fig. 654. — Hogden's splint. This splint may be used as a double inclined plane. 
The manner in which the ropes are arranged affords traction as well as suspension. 

Repeated attempts at reduction of an epiphysis, with intervals of 
delay, are absolutely to be condemned. The sequel of such surgery 
is amputation. If the first attempt is unsuccessful, operation should 
be performed at once. 

Operative Treatment. — Operation is indicated when good reduc- 
tion cannot otherwise be accomplished. An incision along the inner 
border of the cpiadriceps extensor will expose the fragments, and 
manipulation of the lower extremity may be aided by direct trac- 
tion on the displaced fragments, by means of bone hooks or forceps. 
Increasing the angular deformity may render reduction easy which 
would otherwise have been difficult. After the serrated surfaces 



FRACTURES OF LOWER END OF FEMUR 583 

have been engaged the angular deformity is corrected and the frag- 
ments brought back into good alignment. If the fracture is of the 
T-type it is often advisable to make two longitudinal incisions, one 
on the inner and the other on the outer aspect of the thigh opposite 
the lower end of the bone. With the parts thus exposed the condyles 
are forced together and back into position so that they properly fit 
the articular surfaces of the tibia. If a tendency tow^ard recur- 
rence of deformity is noted they should be secured in proper rela- 
tion with each other by some means of internal fixation. If two 
holes are drilled transversely through the lower end of the bone 
above the cond3^1es, a w^ire may be passed through the bone from 
one side to the other and back again, thus holding the fragments 
together. A Lane plate may be used on the anterior surface of the 
bone if the displacing strain is not too great. It should be remem- 
bered that the lower end of the femur is covered by a very thin 
layer of compact tissue w^iile the interior of the bone is composed 
of a cancellous structure wiiich offers an exceedingly poor foothold 
for screws, nails or pegs. The most secure fixation, therefore, is the 
transverse wiring just described. If transverse wiring is employed 
below the upper border of the trochlea care should be exercised to 
avoid drilling into the supracondyloid notch. The drill holes 
should, therefore, be placed well forward. (See ''Anatomy of 
Low^er End of Femur," page 574. 

The knee-joint should not be opened unless it is found that 
proper fixation cannot otherwise be obtained. With reduction and 
fixation of the fragments accomplished the wound or wounds are 
closed and the lower extremity immobilized in whatever position 
shows the least tendency toward recurrence of deformity, as demon- 
strated during operation. Extension, semiflexion or flexion may 
be employed. As a rule, however, it will be found practicable to 
immobilize the lower extremity on a ham splint in a position just 
short of complete extension. When the fracture is treated in this 
position a Buck's extension following operation is usually indi- 
cated to relieve the muscular spasm, steady the member and re- 
lieve the pressure between the articular surfaces of the tibia and 
femur. Padding of the splint for the purpose of exerting pres- 
sure in the popliteal space to effect or maintain reduction is not 
permissible. Tenotomy of the tendo Achillis to overcome backward 
displacement of the lower fragment has been advised and prac- 



584 FRACTURES AND DISLOCATIONS 

tised but is probably an unwise measure. It is often unsuccessful 
and by no means as satisfactorj^ as open treatment with direct 
fixation of the fragments. 

There is usually little tendency toward recurrence of deformity 
following reduction of an epiphyseal separation, if the lower ex- 
tremity is treated in the semiflexed position. Should the excep- 
tion, however, be encountered and internal fixation prove necessary, 
absorbable suture material is the only material which should be 
used in holding the epiphysis in place. Loops of wire or a Lane 
plate should not be used across an epiphyseal cartilage. A light 
plaster cast extending from the groin to the ankle with the knee 
in semi-flexion will usually be found quite satisfactory in im- 
mobilizing the parts. It should not, however, be employed until 
after the traumatic reaction has subsided. If the cast is cut open 
before the plaster has dried it may be applied immediately fol- 
lowing the operation. 

After-Treatment. — Considerable traumatic reaction usually fol- 
lows the accident, and during the first week repeated adjustments 
will be necessary in making allowances for the onset and subsidence 
of swelling. Traumatic arthritis of the knee is the rule, especially 
in epiphyseal separations and fractures entering the joint cavity. 
The knee should be snugly bandaged and an ice cap should be kept 
in position most of the time during the first week. A long side 
splint such as used in fractures of the shaft of the bone, adds 
greatly to the security of immobilization when the fracture is 
treated in the extended position. If the lower fragment shows a 
tendency to posterior displacement not controlled by straight 
Buck's extension, a double incline plane should be employed or the 
lower extremity put up in a cast in a flexed or semi-flexed position. 
At the end of six or eight weeks the dressings should be removed 
and passive motion begun. In another week or ten days the pa- 
tient may be allowed out of bed and may begin the use of the 
member cautiously. He may bear a little weight on it while get- 
ting about with the aid of crutches and a moderately high sole on 
the opposite foot. 

In children union is much more rapid while in the aged it may 
be very much delayed. 

The usual treatment of epiphyseal separations is with the knee 
in a position of semiflexion. At the end of three or four weeks 
the knee may be carefully brought to the extended position and 



FRACTURES OF LOWER END OF FEMUR 



585 



massage beguu. Guarded passive motion should be instituted 
within the next few days. At the end of six weeks all dressings 
should be removed and the child allowed to lie unrestrained in bed 




Fig. 655. — Ambulatory pneumatic splint (adjustable), showing application for all 
fractures but the hip, without any additional supports to the limb or hip-joint immobilizing 
attachment. 



for _ another two weeks. If the ambulatory pneumatic splint is 
used, or some other equally efficient appliance, the child may be 
up and about during this time. Function may be resumed grad- 
ually during the eighth and ninth weeks. At the end of two and 



586 FRACTURES AND DISLOCATIONS 

a half months the patient should be bearing his full weight on 
the leg. 

If at any time during the after-treatment gangrene or septi- 
cemia should develop as a result of destroyed circulation or infec- 
tion, prompt amputation will usually be necessary to save the 
patient's life. 

Prognosis. — Fracture of the lower end of the femur is at best a 
serious condition. Infection of the knee-joint or laceration of the 
popliteal artery are conditions which render the fracture itself 
only of secondary importance. Epiphyseal separation has a par- 
ticularly bad prognosis, especially when compound. Gangrene of 
the leg is not an uncommon sequel when the popliteal artery is 
injured and death has resulted in many instances from gangrene, 
infection, embolism, etc. Disturbances in the subsequent growth 
of the bone following epiphyseal separations are not common if 
recovery has taken place with the fragments in good reduction. 
The surgeon, however, should warn the parents of the untoward 
possibility so that he may not be unjustly blamed later on. 

Simple fracture of the lower end of the femur without arterial 
damage is usually followed by good function if the condyles do not 
unite in deformity. Joint adhesions may occur in the knee. Their 
severity is lessened by the proper use of Buck's extension during 
the height of the traumatic arthritis. A chronic villous arthritis 
is not uncommonly seen following fractures in this region. 



CHAPTER XL. 

FRACTURES AND LUXATIONS OF THE SEMILUNAR 
CARTILAGES. 

Surgical Anatomy. — The semilunar cartilages are two crescentic 
masses interposed between the articular surfaces of the tibia and 
femur and serve to deepen the articular surfaces on the head of 
the tibia. The superficial margins are thick, correspond roughly 
with the outline of the upper end of the tibia and are attached to 
the deep surface of the capsule of the knee-joint. The central 
margins of these cartilages are thin and lie free in the joint. Be- 
tween the articular surfaces of the tibia we have attached from 
before backward : the anterior end of the internal semilunar carti- 
lage, the anterior crucial ligament, the anterior end of the external 
cartilage, the posterior end of the same cartilage and, lastly, the 
posterior crucial ligament. It will be seen from this, that the two 
extremities of the external cartilage practically meet at the spine 
of the tibia while the extremities of the internal cartilage are 
separated by a considerable distance. The deep structure of these 
cartilages is fibrous while the surface is composed of hyaline carti- 
lage. They are triangular on cross-section. The circumference of 
each cartilage is bound to the borders of the tuberosities of the 
tibia by the capsule of the joint, which is continuous on the outer 
and inner aspects of the articulation with the lateral ligaments. 
The portion of the capsule thus attaching the cartilages to the tibia 
is known as the coronary ligaments, and fibres stretching between 
the anterior convexity of the two cartilages has been described as 
the transverse ligament. The knee-joint is of the hinge type with 
complimentary gliding and rotary motion. In extension, lateral 
motion is prevented by the lateral ligaments, but in flexion this 
function is performed by the crucial ligaments. The angle at 
which the tibia joins the femur in extension, normally throws 
greater strain on the internal lateral ligament than on the external. 
The internal cartilage is much more intimately attached to the in- 
ternal lateral ligament than is the external to the external lateral 

587 



588 , FRACTURES AND DISLOCATIONS 

ligament. Rupture and displacement of the internal lateral liga- 
ment will therefore be much more likely to disturb the internal 
cartilage than would be the case with the external cartilage if the 
external ligament were injured. The normal lateral angle of the 
knee is such that the longitudinal stress produced by the weight of 
the body tends to separate the articular surfaces on the inner side 
of the joint. The circumference of the cartilage is attached to the 
internal lateral ligament and when this structure is torn the carti- 
lage may be displaced inward and jammed between the articular 
surfaces. When the femur is displaced laterally on the tibia the 
condyles ride upward on the semilunar cartilages and thus serve 
to bring the crucial ligaments to a tension. In sprains of the knee 
the semilunar cartilages may be fractured or displaced. They may 
be found free in the joint or only partially detached. A portion 
of the cartilage may be fractured and partially or completely 
separated from the remainder. It may be folded upon itself and 
in cases of long standing various degenerative changes have been 
noted in the entire joint as well as in the cartilage. Cases are on 
record in which the cartilage from one side of the articulation has 
been found on the opposite side of the joint cavity. 

Symptoms. — In the typical case the clinical picture is quite 
characteristic. The patient gives a history of having been taken 
with severe pain in the knee (usually on the inner side) while the 
joint was partly flexed and under strain. The joint locked, so 
that he was unable to extend the leg, though it may have been 
possible for him to hobble some distance Avith the knee in a position 
about half way between complete extension and semiflexion. By 
repeated attempts at flexion and extension or with medical aid 
something was felt to give within the joint and the knee was again 
found to be free and capable of full extension. 

Following the accident evidences of traumatic arthritis develop 
and the patient is confined to the house for a period varying from 
a few days to a few weeks according to the severity of the reaction. 
It is during this time that the surgeon usually first sees the case. 
If the patient gets about as soon as the swelling subsides recurrence 
of the accident is almost sure to occur when the knee is subjected 
to similar strain and position. The reaction following subsequent 
luxations is usually less severe than that attending the first dis- 
placement. In the atypical case there may be no history of the 
knee having locked. The patient may complain only of a sense of 



FRACTURES AND LUXATIONS OF SEMILUNAR CARTILAGES 



589 



insecurity in the joint and of pain under strain, at times. In old 
cases the only evidences of the condition may be found in secondary 
changes such as chronic hypertrophic arthritis. For a number of 
days following the accident it is the rule to find tenderness in the 
region of the cartilage, usually the internal, and in some instances 




Fig. 656. — Subluxation of the knee Avitli later;ri disluratiuu i.l the patella. The in- 
ternal lateral ligaments are torn and the semilunar cartilage displaced toward the spine 
of the tibia. 




Fig. 657. — ^Another view of the same case showing 
between the tibia and femur. 



how the finger may be inserted 



a gap between the bones may be produced by manipulation. Pain 
may be referred to the patella rather than the region of the carti- 
lage though the tenderness is always more pronounced at the site 
of the cartilage. The absence of physical signs, however, is char- 
acteristic following the traumatic reaction. When the condition 



590 . FRACTURES AND DISLOCATIONS 

becomes recurrent it is not infrequently quite disabling. The time 
consumed in recovering from the traumatic reaction and the sense 
of insecurity which the patient experiences during the intervals 
are important sources of disability. The fact that the knee may 
be thrown out of function at any time deters him from many ac- 
tivities. The degenerative changes which so often follow in the 
articulation are important. 

Diagnosis. — With the typical history of sudden pain and "lock- 
ing" of the joint, with complete release of the articulation when 
the cartilage is reduced, the diagnosis is easy. In atypical cases, 
however, without the characteristic symptoms of locking of the 
knee, it may be impossible to arrive at a diagnosis until the joint is 
explored. It might seem that a diagnosis should be made in all 
cases, yet experience will show that mistakes are common even 
among those most thoroughly versed in the internal derangements 
of the knee. When the case is not typical the condition must be 
differentiated from : dislocations of the patella, synovial fringes, 
joint mice, lipomata and subluxations of the knee. 

If the patient is seen daring the acute disability there will be 
little difficulty in differentiating lesions of the semilunar cartilages 
from luxations of the patella. If, however, we are obliged to rely 
on the history given by the patient it may become an extremely 
difficult matter to arrive at a diagnosis. If the patella has been 
dislocated the region of the knee cap will be tender for a few days 
following the displacement and it is often possible, especially under 
anesthesia, to displace the bone beyond its normal limits. More- 
over the characteristic tenderness on the inner side of the knee at 
the site of the semilunar cartilage is absent. If the case is seen 
some weeks or months following the accident it may be impossible 
to determine the conditions that existed, if the patient gives the 
usual imperfect history. When synovial fringes are pinched, the 
locking is not as pronounced and solid as occurs in luxations of 
the semilunar cartilages. IMoreover the point at which the motion 
of the knee is interfered with is not constant and the pain is usually 
more intense and acute than occurs when the semilunar is at fault. 
When joint mice are present it may be possible to palpate one or 
more of the loose bodies within the articulation, and the point at 
which the action of the knee is interfered with varies with different 
attacks. If the disturbance in function is due to lipomata the acute 
symptoms are less severe and the subsequent acute traumatic ar- 



FRACTURES AND LUXATIONS OF SEMILUNAR CARTILAGES 591 

thritis is usually negligible. In addition a permanent puffiness is 
usually noted on either side of the patellar ligament which repre- 
sents the enlarged fat pad beneath the ligament. In subluxations 
of the knee the history of trauma and the abnormal mobility will 
usually clear the diagnosis. The joint cavities have been injected 
with hydrogen and the X-ray used to determine the outlines of the 
semilunar cartilages but this method of diagnosis is seldom indi- 
cated in general practice. When it is employed the dangers of 
infecting the articulation should be kept in mind. In chronic dis- 
turbances of the knee the important points to be determined are 
whether or not the disturbance in function is sufficient to warrant 
opening the knee and whether or not good functional results can 
be obtained without operation. 

Treatment. — If the case is seen while the cartilage is luxated, 
reduction should be effected at once. Reduction of the displaced 
cartilage is usually easy though cases are occasionally encountered 
in which open incision is necessary. Reduction is effected by acute 
flexion of the knee, the leg is then rotated back and forth on its 
axis and laterally deviated from side to side and finally extended. 
In acute flexion of the knee the most convex portions of the femoral 
condyles are in contact with the articular surfaces of the tibia and 
accordingly there is more room for the cartilages than when the 
knee is extended. This accounts for the release of the pinched 
cartilage during acute flexion. The rocking and rotary motions 
just described also tend to free the cartilage. If the surgeon flexes 
the knee over his wrist, the latter acts as a fulcrum and aids ma- 
terially in separating the articular surfaces of the femur and tibia. 
If these manipulations have been successful and the cartilage has 
been freed, complete and active extension of the knee will be pos- 
sible and painless. If they have failed the knee, will be blocked 
just short of full extension and the patient will be unable to hold 
the leg extended in the horizontal position. Moreover the attempt 
will be attended by pain. The proof of reduction is the free active 
extension of the joint unattended by pain. The patient will almost 
invariably be able to state when the cartilage is reduced. His con- 
duct reminds one of luxations of the shoulder in which the sufferer 
exclaims with satisfaction as the head of the bone slips back into 
the glenoid. The care of the case following reduction will be taken 
up in the after-treatment. 

Operative Treatment. — The indications for operative treatment 



592 FRACTURES AND DISLOCATIONS 

var}^ with the social state of the patient and the nature of the 
lesion. If this luxation occurs for the first time in a gentleman 
of leisure, who has ample time for non-operative methods and can 
avoid subsequent strain to the joint, the condition may be treated 
expectantly. If on the other hand the patient is a laboring man, 
whose time and activity mean his living, the cartilage causing the 
trouble should be removed at once. The advisability of operating 
following the first luxation is a question. If reduction is accom- 
plished and the joint immobilized for a period sufficiently long to 
allow complete healing of the ligaments and cartilage, the condition 
may not recur. Cases of habitual luxation, with or without evi- 
dences of degenerative changes within the joint, call for operative 
intervention. Nothing can be expected from non-operative meth- 
ods under these circumstances. 

A vertical incision is made beginning about one inch behind the 
lateral border of the patella and a little above the horizontal plane 
of the articulation. This is carried downward across the articu- 
lation and continued backward in a curved direction as soon as the 
scalpel comes opposite the tuberosity of the tibia. After the skin 
incision is made the cutaneous edges are covered with gauze, which 
is held in position by tenaculse. The tissues are then divided down 
to the capsule of the joint, which is incised with the least possible 
trauma. The half of the joint cavity to be operated upon is then 
open for inspection and the nature of the lesion may be determined. 
The most rigid asepsis sliould he ohserved; the gloved fingers should 
not be introduced within the articulation and instruments having 
come in contact with the hands should not enter the cavity. 
Sponges should be used but once. If the cartilage is fractured, 
detached (partially or completely), folded upon itself or degen- 
erated it should be removed. Anchoring of the cartilage to prevent 
luxation should not be attempted as the results are not satisfactory. 
Removal of the cartilage should be accomplished with as little 
trauma as possible. If other derangements are encountered within 
the articulation they should be corrected. Following operation the 
joint should be immobilized and an ice cap applied to the knee to 
control any traumatic arthritis which may develop. 

After-Treatment. — The care of the case following non-operative 
reduction consists in immobilizing the knee on a posterior splint in 
complete extension. Elevation of the lower extremity and the use 
of the ice cap will tend to control the traumatic reaction. If trau- 



FRACTURES AND LUXATIONS OF SEMILUNAR CARTILAGES 593 

matic arthritis develops Buck's extension should be employed. 
Immobilization should be maintained for a period of three weeks 
and the resumption of function should be gradual. Strain to 
the knee in the flexed or semi-flexed position should be avoided for 
three or four months. If the inner side of the sole of the shoe is 
built up and the patient forms the habit of "toeing in" in walking, 
much of the strain will be removed from the internal lateral liga- 
ment and thus the chances of recurrent luxations of the internal 
semilunar will be reduced. Following operation and removal of 
the cartilage motion may be begun at the end of ten days and the 
patient may return to w^ork within two weeks if there are no com- 
plications. 

Prognosis.^ — Fracture or dislocation of a semilunar cartilage may 
occur only once if proj^er immobilization has been carried out fol- 
lowing the accident. If on the other hand function is resumed 
immediately or as soon as the traumatic arthritis has subsided, re- 
currence is almost sure to follow. Restoration of function fol- 
lowing operation is prompt and complete. The patient is able to 
resume his original occupation or to follow the sport in which the 
injury was sustained. 



CHAPTER XLI. 

FRACTURES OF THE PATELLA. 

Surgical Anatomy. — The patella is a sesamoid bone developed in 
the tendon of the quadriceps extensor femoris. It is usually ossi- 
fied from one center, which makes its appearance about the third 
year. In rare instances it is developed from two centers, laterally 
placed. The patella is attached to the tubercle of the tibia by the 
ligamentum patellae, Avhich maintains the bone at a constant dis- 
tance from the tibia. The anterior surface is subcutaneous except 
for the prepatellar bursa which is interposed between the bone and 
the skin. The patella is covered on all sides, except the articular 
surface, by the tendon of the quadriceps which is spoken of below 
the bone as the ligamentum patellae. In extension of the knee the 
articular surface of the patella is in contact with the trochlear 
surface of the femur ; in flexion, with the condyles. The lower 
portion of the patella or apex has attached to it, both anteriorly 
and posteriorly, the fibres of the ligamentum patellae. 

The patella is situated in two fibrous planes; the superficial one 
is represented by the fascia lata covering the quadriceps extensor, 
the deep plane is the capsule of the knee-joint. When fracture 
occurs separation of the fragments does not take place unless the 
fascial planes, in which the bone is situated, are torn. The func- 
tion of the patella is to afford leverage to the tendon of the quadri- 
ceps, while acting across the flexed knee. The insertion of this 
muscle is chiefly into the patellar ligament, but it should not be 
taken for granted that the quadriceps acts only through the patella, 
since it finds a broad insertion into the upper end of the tibia 
through the fascia lata and capsule. In instances, therefore, in 
which the patella is fractured without tearing of the fasciae on 
either side of it, the patient still retains some power in extending 
the knee. 

The mechanism of fracture of the patella has been the subject 
of considerable discussion, and even at the present time differences 
of opinion exist concerning it. The bone may be broken by direct 

594 



FRACTURES OP THE PATELLA 595 

violence, or by mnsciilar action. When the former is the cause 
the fracture is often stellate or irregular and comminuted, depend- 
ing upon the nature, direction and degree of the trauma. In this 
type of fracture the lateral fasciae are seldom torn and the dis- 
placement is slight. Fracture produced in this way sometimes re- 
sults in injury to the underlying articular surface of the femur. 
When fracture results from muscular action it is caused by the 
violent action of the quadriceps extensor on the patella while the 
knee is flexed. In this way the patella is broken across the con- 
dyles of the femur, and if the muscle continues to act, the frag- 
ments are separated and the lateral fasciae torn. 

The mechanism of fracture of this bone, as a result of muscular 
action, may be illustrated by the facility with which a stick can 
be broken across the knee when it will be impossible to part this 
same stick by simple traction and counter-traction in its long axis. 
If a blow is sustained on the flexed knee (either by a moving object 
or in a fall) while the muscle is contracting, the fracturing effect 
of the muscular pull is greatly increased. The upper end of the 
bone is fixed by the quadriceps and the lower end by the liga- 
mentum patellae, while the middle of the posterior surface is the 
only part of the articular face in contact with the femur during 
flexion. The distribution of these three forces explains the man- 
ner in which the patella may be snapped. 

Fracture of the patella nearly always enters the knee-joint, but 
when confined to the lower portion of the apex of the bone, which 
is covered by the patellar tendon, the joint is not necessarily opened. 

Etiology. — Transverse fracture of the bone is most common, while 
the comminuted form is next in order of frequency. Over four- 
fifths of all fractures of the patella are in the lower half of the 
bone. This accident occurs more often between the ages of thirty 
and forty, and is three times as common in males. Muscular action 
is probably responsible for more cases than is direct violence, al- 
though a combination of these two elements is not at all uncommon. 

Symptoms. — Local pain is constant, with partial or complete loss 
of extension at the knee. The patient is sometimes able to walk 
backward by dragging the foot and keeping the knee hyperex- 
tended. If weight is put upon the leg, with the slightest degree 
of flexion at the knee, the lower extremity buckles and the patient 
falls. The condition is usually simple, although in severe crushing 
or cutting injuries the fracture may be compound and the joint 



596 



FRACTURES AND DISLOCATIONS 



exposed. Crepitus may be elicited in the absence of separation, 
or if the parted fragments are drawn toward each other and the 




Fig. 658. — Old fracture of patella with separation of fragments. Recent fracture 
of the femoral neck, which accounts for the complete eversion of the entire lower extrem- 
ity. The front of the knee looks outward instead of upward and the depression between 
the fragments of the patella is just above the point of the arrow. 

serrated surfaces rubbed together. Some degree of separation is 
usually present, which in many instances can be detected by in- 
spection alone if the case is seen before the parts become exten- 
sively swollen. It is often possible to lay one or two fingers in the 




Fig. 659. — Shows an unusual case of fracture with wide separation of both patellge. 
The fracture of the left patella is of three years' standing Avhile that on the opposite side 
is two years old. Case treated by the expectant method which resulted in fibrous union 
with subsequent separation of the fragments. Case first seen bv the author three years 
after the first fracture. 

depression existing between the fragments. Swelling and disten- 
tion of the joint follow rapidly, and obliterate the depression be- 



FRACTURES OF THE PATELLA 597 

tweeii the fragments so that the condition cannot be recognized by 
inspection, although there is usually little difficulty in determining 
the deformity b}^ palpation. The development of ecchymosis within 
twelve or twenty-four hours of the injury is the rule. It is usually 
most pronounced on either side of the patella corresponding to the 
positions of the lateral fascial tears. 

The symptoms of acute traumatic arthritis generally supervene 
within a few hours of the injury. Swelling, redness, pain, tender- 
ness and distention of the joint are present. When the joint be- 
comes filled, the fluid reaches the surface between the fragments 
and produces a prominent swelling anterior to the patella. Dis- 
tention of the joint cavity causes the patient to assume a charac- 
teristic position of slight flexion of the knee and moderate eversion 
of the thigh. The later symptoms of fracture of the patella depend 
largely upon the line of treatment followed. Pain, swelling and 
tenderness are usually not severe at the end of a week or ten days, 
especially if measures have been instituted for their control. 

Bony union seldom occurs in cases which have been treated by 
non-operative methods and the amount of impairment in function 
will depend largely upon the length and strength of the fibrous 
union. This fibrous tissue tends to stretch with the subsequent 
use of the member, so that it is not uncommon for the patient to 
present himself for treatment at the end of a year or two because 
of pronounced and increasing loss of function. The separation 
between the fragments may be four or five inches or even more, so 
that the quadriceps extensor can be well contracted while the knee 
is still in a position of semiflexion. Secondary separation of the 
fragments is not prone to occur if the lateral fasciae were untorn 
at the time of injury. Fibrous adhesions or bony union between 
the articular surface of the patella and the femur, may so fix the 
knee cap that the thigh muscle cannot move it, thus producing loss 
of function of an entirely different character. 

Diagnosis. — The diagnosis is based on the history of injury to the 
knee followed by prompt loss of function and other symptoms just 
enumerated. Little difficulty should be experienced in recognizing 
the condition by inspection and palpation regardless of Avhether or 
not separation of the fragments exists. Even though the bone is 
superficial and easily palpated, nevertheless it is advisable to have 
an X-ray taken to accurately determine and record the details of 
the fracture. 



598 



FRACTURES AND DISLOCATIONS 



Treatment. — The fact that reduction of the separated fragments 
is indicated in the treatment of fracture of the patella, is uniformly 
conceded, but the proper method of attaining tliis end has been, 
and is, the subject of mucJi discussion. Even at the present time 
few surgeons agree concerning the best method of procedure. Some 
are opposed to opening the knee-joint as long as there is a fair 
prospect of obtaining some kind of a functional result by non- 
operative methods. Others take the position that every fracture 





Fig. 660. — Shows the non-operative treatment of fracture of the patella. A. shows 
the lower extremity fixed on a posterior splint with the knee in a position of slight flexion. 
The splint is a straight splint heavily padded opposite the knee. Two short splints are 
secured to the thigh on either side of the quadriceps to prevent contraction of this muscle. 
B. shows diagonal strips of adhesive applied above and below the patella to approximate 
the fragments. C. shows lateral splints applied. D. shows the lower extremity raised on 
pillows to relax the quadriceps. 



of the patella should be subjected to open treatment if the general 
condition of the patient will permit of operation. Personal ex- 
perience and observation have indicated that by far the best results 
follow the more radical measures. It is a well known fact that ex- 
cellent functional results are sometimes seen in instances in which 
wide separation and heavy fibrous union are present. But on the 
other hand the highest percentage of functionally perfect results is 
seen in cases in which accurate anatomic reduction has been accom- 
plished. Conclusive deductions cannot, at the present time, be 



FRACTURES OF THE PATELLA 



599 



drawn from the statistics of operated eases because of the widely 
varying and sometimes imperfect technique which has been fol- 
lowed b}' different operators. In the author's opinion, non-oper- 
ative treatment is only indicated in old and feeble persons, or in 
cases in which separation does not exist. The lack of proper sur- 
gical facilities and skill or the presence of certain constitutional 
diseases, such as diabetes, wdll of course act as contraindications 
to the open treatment. The first indication in the treatment of 
fracture of the patella, in both the operative and non-operative 
methods, consists in putting the lower extremity at rest and in 




Fig. 661. — "Shaped" ham splint with padding applied to posterior aspect of lower 
extremity and held in position by three strips of adhesive plaster. 



instituting measures to control the traumatic arthritis. The lower 
extremity should be placed upon a posterior splint, which is secured 
in position by bandages and strips of adhesive as shown in Fig. 
660. A snug bandage should cover the knee to control the swell- 
ing, and an ice cap to the parts will be found of great service in 
relieving pain and modifying the inflammatory reaction. If the 
expectant method is to be followed adhesive straps above and below 
the patella are diagonally placed in such a manner as to draw the 
fragments together (see Fig. 660). It is useless, however, to at- 
tempt to approximate the fragments until the joint distention lias 



600 



FRACTURES AND DISLOCATIONS 



subsided, which will not be sooner than one week following the 
injury. There is no method of applying these straps, even after 
the fluid has left the joint, which will accurately approximate the 
fragments if separation has existed, notwithstanding statements to 
the contrary. This fact may be conclusively demonstrated by the 
use of the X-ray in any given case in which the fragments are 
supposed to have been reduced. In the rare instances in which 
fracture has occurred without separation of the fragments, as indi- 
cated by the X-ray, this method may be counted upon to give a 
good result. In most cases of fracture of the patella considerable 
separation will be found after everything which is possible in a 
non-operative way has been accomplished, and we therefore turn 
to the open treatment to secure reduction. 

Operative Treatment. — The open treatment of fracture of the 
patella is the ideal method, but should not be attempted unless one 
fully appreciates the untoward possibilities, and is thoroughly 
equipped to carry it through. If the cases, in which unsatisfactory 





Fig. 662. 

Fig. 662. — Shows tlie method of placing the silver wire mattress suture in approxi- 
mating the fragments in a transverse fracture of the patella. 

Fig. 663. — Shows a horizontal section of the patella at the same level. Note the rela- 
tive distribution of cancellous and compact tissue. 



results have followed the open treatment, are analyzed, they will 
be found to have resulted from one or more of three conditions, 
namely : infection, insecure fixation of the fragments and prolonged 
immobilization of the knee. 

Asepsis should be perfect in every detail as described under 
"Open Treatment of Fractures" on page 754. Infection follow- 
ing operations on the knee means not only failure in union, but 
involvement of the knee-joint which may result in loss of function 
in the articulation, if not amputation or death. It is common to 
find a clot of blood in the joint behind the fracture, which should 



FRACTURES OF THE PATELLA 



601 



be removed before the fragments are brought together. It is dan- 
gerous to leave this dead blood where it may favor subsequent sup- 
puration (see "Open Treatment of Fractures," page 754). The 




Fig'. 6(.i4. — Recent fracture of the patella with separation of fiii<i-nients. This 
near as the fragments could be brought together by non-operative methods. 




Fig. 665. — ^Same case after operation. A silver Avire, mattress suture draws the 
fragments into apposition and holds them firmly against the displacing action of the 
quadriceps. Ultimate result, complete restoration of function. 

fragments should be accurately and firmly approximated at the 
time of operation and so fixed that separation cannot take place 
during the after-treatment. Wire properly placed is the only 



602 FRACTURES AND DISLOCATIONS 

material which can be counted on to secure proper and permanent 
immobilization. Absorbable suture material has been strongly ad- 
vocated and good results may follow its employment ; but the inse- 
curity resulting from its softening and absorption before the end 
of the third week should condemn its use in fracture of the patella. 
It has been used in suturing the fasciae covering the patella and in 
the repair of lateral fascial tears as well as in direct suturing of 
the bones through drill holes. Separation of the fragments is likely 
to occur during the second or third weeks, which can only mean 
failure in bony union with the possibility of further separation 
through stretching of the fibrous tissue. Even if chromicised cat- 
gut or other absorbable material could be counted on to maintain 
reduction until bony callus relieved it of strain, we could not rely 
on the sutured fascia to withstand the pull of the quadriceps dur- 
ing this period. It is apparent, therefore, that wire, securing a 
firm hold directly on the bony fragments, is the most satisfactory 
method of fixation. The structure of the patella should be remem- 
bered w^hile securing the fragments. The wire should be so placed 
that it obtains its hold on the compact shell, rather than on the 
internal cancellated tissue, which is likely to give way under strain 
and allow the loop of wire to tear out. This is best accomplished 
by a mattress suture of wire as described later on. The more se- 
cure the internal fixation, the safer is the early employment of 
passive motion ; and early passive motion is most essential in re- 
establishing the function of the joint. Its proper use will be de- 
scribed in the after-treatment. Loss of function and "painful 
joint" sometimes occur in cases in which proper reduction and 
bony union have followed the injury. These conditions are almost 
entirely due to the lack of early passive motion. The joint should 
be moved not later than two weeks from the time of operation, but 
passive motion has its risk, if fixation of the fragments is not solid, 
and should not be attempted without properly guarding the patella 
from the action of the quadriceps. 

The following technique, in operating on fractures of the patella 
has proven the most satisfactory in the author's hands and may 
be considered the procedure of preference in most cases. An in- 
cision is made exposing the fragments ; it may be longitudinal and 
directly over the fracture or of the U-shape commonly employed 
in operations on the knee. With the fragments exposed and sepa- 
rated the clot w^hich is usually found behind the fragments is re- 



FRACTURES OF THE PATELLA 



603 



moved with thumb forceps. Bony contact is essential and if fascia 
is found covering one of the fractured surfaces (usually the lower) 
it should be carefully removed before the fragments are brought 
together. In transverse fracture of the patella holes are drilled 
in each fragment so that the drill enters the anterior face of the 
patella and comes out on the fractured surface. Two such parallel 
holes are drilled in each fragment so that the openings on the 




Fig. 666. — Wired fi'actiire of the patella three years af^er in.iury. Funrtion as 
good as before accident. Note silver wire which crosses line of fracture twice but does 
not enter joint. Accident in 1905; wire in place at the present time. 

Fig. 667. — Wired fracture of the patella two years following accident. Patient 
failed to follow instructions, got out of bed and walked about shortly after operation 
with the result that the wire was broken. It held, however, sufficiently well to secure 
a functionally perfect result. This case demonstrates the advisability of using heavy wire 
which is as well tolerated by the tissues as lighter material. Compare this case with 
the one shown in Figs. 665 and note the size of the wire. 

fractured surfaces are opposite the corresponding openings of the 
holes on the other fragment. A heavy silver wire is then threaded 
through these holes so that the two ends are above the line of frac- 
ture (see Fig. 662). The fragments are then drawn together until 
they are in firm apposition and then the ends of the wire are 
twisted together, cut off, and turned in toward the bone. This 
mattress suture will securely hold the fragments in simple transverse 



604 FRACTURES AND DISLOCATIONS 

fracture of the patella and in addition may be made to work well 
when three fragments are present instead of two. In the 
presence of comminution it may be impossible to make the 
mattress suture hold because of the breaking up of the compact 
tissue, and when such is the case a circular wire surrounding the 
comminuted bone may serve the purpose. A specially formed Lane 
plate has been devised to be used on the patella but the nature of 
the bone and the difficulty of making the screws hold, results in 
wire being the material of choice in the open treatment of this 
fracture. When the wire is placed there should be no motion in 
the fragments nor in the wire: in other words the fixation should 
be as secure as possible, to obtain the best results. ' The knee should 
be flexed and extended before the wound is closed to see that the 
action of the joint does not disturb the fixation. The skin incision 
is then closed and a few strands of silk-worm are left in the lower 
angle of the wound to allow the escape of fluids following operation. 
If the vertical incision is employed directly over the fracture, a 
subcutaneous running suture should be so placed that it will bring 
as much of the soft tissues between the fracture and the skin as 
possible. 

Fracture of the patella is sometimes compound from the first, 
with the joint exposed and infected at the time of the accident. 
When such is the case, the condition of greatest importance is in- 
fection of the knee-joint. This is a serious matter and if not prop- 
erly controlled may necessitate amputation, or may even result in 
death from a general sepsis. The opening of the joint should be 
increased in size if not already sufficiently large, and the edges of 
the wound should be trimmed away until all traces of crushed and 
devitalized tissue are removed. The joint should then be irrigated 
with a few gallons of warm physiologic salt solution. In irrigat- 
ing the wound a soft rubber catheter should be used, and carried 
to the innermost recesses of the articulation so that the flow will be 
directed from the interior of the joint to the surface. After the 
articulation has been thoroughl}^ washed out, the soft tissue should 
be accurately approximated and the joint closed as tightly as pos- 
sible with the idea of preventing subsequent leakage. The cavity 
of the knee is then injected with Murphy's Formalin Glycerine 
solution, the patient put to bed, the lower extremity elevated. 
Buck's extension applied and an ice cap kept on the knee. Sub- 
sequent injections of the formalin glycerine solution are made 



FRACTURES OF THE PATELLA 605 

according to the amount of leakage through the incision and the 
reaction occurring in the articulation. This method of treating 
infected joints, devised by IMurphy, is productive of such vastly 
better results that no other form of treatment should be considered 
until after this has been tried. If suppuration of the joint can 
be avoided in this way, suturing the patella may be done at the 
end of two or two and a half weeks Avhen the dangers of articular 
infection have passed. 

Suturing of the patella immediately following the accident 
should not be done in compound cases. The joint infection should 
be treated first and the fracture reduced in a secondary operation. 
If infection of the joint cannot be controlled by the initial irriga- 
tion and subsequent injection, it should be opened and freely 
drained, and under such circumstances approximation of the patella 
will be of little importance, since ankylosis of the knee-joint will, 
in all probability, be the result. If the accident occurs in a region 
of the country in which tetanus prevails, the patient should receive 
a prophylactic dose of anti-tetanic serum. 

AYhen operation is done for the secondary separation which 
sometimes follows fibrous union the method of procedure is similar 
to that already described. The fibrous tissue between the frag- 
ments should be excised and the fractured surfaces freshened and 
approximated. It may occasionally be necessary to lengthen the 
quadriceps above the patella to bring the fragments together. 
When the patella is attached to the trochlear surface by -adhesions 
it may be possible to free it by forced passive motion under anes- 
thesia. If the adhesions are too firm to be broken up in this man- 
ner it may be necessary to open the joint and divide them with 
the scalpel. If the adhesions are extensive and show a tendency 
to reform, a transplanted layer of fascia lata may be sutured in 
position to cover the articular surface of the patella. Early passive 
motion, repeated at regular intervals, will then, as a rule, result in 
a freely movable patella and good articular function. 

After-Treatment. — The length of the after-treatment will vary 
according to whether or not the open method has been employed. 
If expectant treatment has been followed immobilization of the 
knee is required for from six weeks to two months, after which 
guarded passive motion is indicated. During the use of the splint 
the dressings should be carefully watched and tightened to keep 
them in proper position. The diagonal straps which tend to pull 



606 FRACTURES AND DISLOCxVTIONS 

the fragments together are likety to become lax, especially as the 
joint distention subsides. During the first two or three weeks, pads 
should be kept on either side of the quadriceps and firmly bandaged 
in position to prevent contraction of this muscle. During the 
stage of articular inflammation the local application of the ice-cap 
will be found of service in controlling the reaction. The lower 
extremity should be elevated on an inclined plane to favor the cir- 
culation of the parts and relax the extensor thigh muscles. Accu- 
rate approximation of the fragments is practically impossible in 
the non-operative treatment, as previously stated, and during the 




Fig. 668. — Method of performing passive motion in the treatment of fracture of the 
patella. The left hand bears down on the ankle thus flexing the knee Avhile the right 
hand pushes downward on the patella to relieve the fracture of the pull of the quad- 
riceps. 

time the joint is distended it will be useless to even attempt dimin- 
ishing the degree of separation; when the fluid has left the joint 
the distance between them may be somewhat decreased by the 
proper application of straps. At the end of two months the splint 
may be discarded and the patient allowed to get about on crutches 
with some more convenient form of joint immobilization. A cast 
of the leg may be made, split up the front before thoroughly dried 
and removed. After the plaster is set the cast may be covered with 
some durable material and strips of leather with hooks, applied to 
the edges on either side of the opening. In this way the cast may 



FRACTURES OF THE PATELLA 607 

be removed at night for the purpose of massage and motion of the 
joint. During the day it is worn and when snugly laced immo- 
bilizes the knee and protects the patella from strain. Motion of 
the knee involving strain, such as walking without splint or cast, 
should be prohibited inside of from six to eight months. Excep- 
tional muscular strain should be avoided for a year. If fibrous 
union is heavy and short, the time may be considerably shortened. 
If it is weak and shows a tendency to stretch, the period of fixation 
and protection of the knee should be increased. 

The period of disability following the open treatment is strik- 
ingly shorter than that just described. The limb should be kept 
on a posterior splint as described in the after-treatment of un- 
operated cases. The dressings should be removed at the end of 
two weeks from the time of operation, and passive motion insti- 
tuted, provided the internal fixation was properly and securely 
accomplished at the time the joint was opened. 

The manner of performing passive motion is of considerable im- 
portance: the knee may be so flexed that the entire strain of the 
thigh muscles is thrown on the patella, or it may be so accomplished 
that the fracture is entirely relieved of the pull of the quadriceps. 
"When the knee-joint has been fixed for a period of two or three 
weeks and the joint has suffered the inflammatory reaction incident 
to traumatic arthritis, it will be impossible to accomplish passive 
motion without producing spasm in the quadriceps, and it is this 
spasm which should be guarded against. If the surgeon places 
the lower extremity across his knee while one hand grasps the 
ankle and the opposite index finger and thumb are pressed into 
the thigh just above the upper border of the patella, he will be in 
a position to perform passive motion and still protect the patella 
from the spasmodic action of the quadriceps (see Fig. 668). As 
the ankle is depressed, thus flexing the knee, the opposite hand 
forces the patella downward towards the knee and takes up the 
strain of the contracting extensors of the thigh. This is the only 
way in which early passive motion can be perform.ed without risk. 
Slight, snapping sensations are sometimes felt by the hand which 
forces the patella downward, but there is no cause for alarm since 
they are produced by the breaking up of adhesions in the joint 
which at this time are too imperfectly organized to act as serious 
obstacles to motion. 

At the end of eight or ten weeks, the patient is allowed to get 



608 FRACTURES AND DISLOCATIONS 

about without any fixation apparatus. It is well for him to carry 
a cane, and favor the injured knee for another two or three weeks, 
and he should be especially cautioned against unusual and excessive 
strains until four or five months have elapsed from the time of the 
injury. It is well to have another X-ray taken at the end of three 
months to determine the presence of bony union. The heavier the 
union, the less caution is necessary. 

Prognosis. — The restoration of function following fracture of the 
patella is a variable quantity. Fibrous union, even to the extent 
of two or three inches, does not necessarily indicate that the pa- 
tient may not enjoy most excellent function. On the other hand, 
accurate reduction and firm union does not necessarily indicate that 
the knee will be restored to its original usefulness. The percentage 
of functionally perfect results, however, is much higher in cases 
in which bony union is present. In the ordinary fractured patella 
we can hardly expect complete restoration of function with any 
form of non-operative treatment. The power of extension is likely 
to be decreased, and the action of the joint impaired, although it 
is not uncommon to find complete flexion possible. "When fibrous 
union occurs, it will be impossible to state whether this union will 
be heavy, strong and efficient, or, on the other hand, thin, weak 
and permitting of subsequent separation of the fragments. Weak- 
ness and painful joint are common sequelse. 

The results following the open treatment are vastly better, pro- 
vided the three requisites previously mentioned, are observed, 
namely : avoidance of infection, secure internal fixation of the frag- 
ments and early and persistent passive motion. Under such cir- 
cumstances the usual result is complete and permanent restoration 
of function, together with absence of pain in the articulation. 



CHAPTER XLII. 

DISLOCATIONS OF THE PATELLA. 

Surgical Anatomy. — There are a few anatomical facts bearing 
directly on dislocations of tlie patella, to be taken np at this time 
without entering into the details of the knee-joint, which were 
considered under fractures of the patella. The pull of the quadri- 
ceps is upward and in a direction parallel with the long axis of the 
femur. The ligamentum patellae lies in the long axis of the tibia 
and since the axis of the tibia is not the same as that of the femur 
it will be apparent that the pull of the quadriceps (with the leg 
extended), is not in line with the long axis of the ligamentum 
patellge. It is evident, therefore, that when the quadriceps con- 
tracts it not only pulls the patella upward but also tends to displace 
it outward. This tendency toward outward displacement of the 
patella is normally counteracted by the outer lip of the troch- 
lear surface of the femur and the attachments of the capsule 
and fascia lata. "When the capsule and fascia lata internal 
to the patella are lax, or when the outer lip of the trochlea is not 
sufficiently prominent, the bone may be displaced outward on vio- 
lent contraction of the extensors of the thigh. The angle at which 
the tibia joins the femur varies considerably in different persons. 
It is usually greater in women because of the proportionately 
broader pelvis and greater divergence of the femora. The angle 
is greater in short stocky persons than in those of tall and slender 
stature. If the knee be fully extended and the quadriceps relaxed 
the patella will be found quite freely movable from side to side 
as well as vertically. If the lower extremity be kept in the same 
position and the thigh muscles tightened the patella immediately 
becomes fixed. This is due largely to the vertical groove in the 
trochlea and the corresponding ridge on the articular surface of the 
patella. It will thus be seen that although the quadriceps has a 
lateral displacing action on the patella, yet the contraction of this 
muscle also tends to prevent lateral displacement (if the fascial 
attachments and trochlea are normal) by forcing the patella into 

609 



610 FRACTURES AND DISLOCATIONS 

the groove on the trochlea. The muscles and fasciae attached to the 
bone often tend to fix it in displacement after dislocation has oc- 
curred. The patella may be dislocated in any direction and is not 
uncommonly found rotated on its axis. If the patella is displaced 
laterally until it clears the trochlear surface, or the bone is com- 
pletely rotated on its axis so that the articular face looks forward, 
the dislocation is said to be complete. If portions of the articular 
surfaces remain opposed or if the bone stands on edge the condition 
is incomplete and is spoken of as a subluxation. These distinctions 
are of degree only, and are more academic than practical. The 
same may be said of the classifications based on the details of the 
possible positions occupied by the patella during displacement. 

F d 






F 



Fig. 670. Fig. 671. 

Fig. 669. — Normal relations between patella and lower end of femur. 
Fig. 670. — Patella luxated outward. Most common type. 

Fig. 671. — ^Represents patella displaced outward and "on edge." Also rotation of 
patella so that the posterior surface looks forward. 

Etiology. — Luxations of the patella constitute less than one 
percent of all dislocations. Displacement may be in any direction 
although the external lateral type is by far the most common. The 
condition may be partial or complete. It is more common in 
women than in men ; in short persons than in tall. Muscular action 
is often responsible for this luxation, although it may be caused by 
direct violence. A combination of these two elements is not un- 
common. 

Symptoms. — Sharp pain occurs at the time the bone is pulled or 
driven out of place, and unless spontaneous reduction occurs (which 
is not uncommon) there will be immediate loss of function wdth 
deformity w^hich can be readily recognized both by inspection and 
palpation. Following the accident symptoms of acute traumatic 
arthritis develop although they are seldom as severe as those accom- 
panying fracture of the patella. The deformity varies with the 
type of displacement. Recurrence of luxations of the patella are 
not uncommon and may constitute a most annoying and disabling 



DISLOCATIONS OF THE PATELLA 611 

condition. In many cases the patient will know just what position 
of the knee or what form of strain is productive of the displace- 
ment, and is always on his guard to avoid the condition while using 
the lower extremity. 

Diagnosis. — If the surgeon sees the condition prior to reduction, 
he may recognize the displacement by the characteristic deformity. 
Palpation of the parts will readily determine, not only the fact that 
the patella is displaced but also, the type of luxation present. In 
instances in which the dislocation has been corrected or spon- 
taneous reduction has taken place, it may be difficult to differenti- 
ate the condition from a fractured or luxated semilunar cartilage. 
A careful history and examination of the parts will usually result 
in determining which of the two conditions has occurred. 

Treatment. — As a rule, little difficulty is experienced in returning 
the patella to its proper position. The knee should be maintained 
in complete extension, w^hile the thigh is flexed on the abdomen to 
relax the quadriceps extensor. If the patella does not then slip 
back into place of itself, slight manipulation will usually suffice to 
reduce the luxation. Before manipulation is attempted the sur- 
geon should have learned the relations of the displaced bone by 
palpation, so that he may cause it to retrace the course taken at the 
time of the accident. When the patella is found rotated on its 
vertical axis it is particularly necessary that the surgeon know in 
which direction rotation has taken place. This is readily deter- 
mined by palpation of the muscle above, and the ligamentum pa- 
tellae below. It is extremely rare to encounter difficulty in reduc- 
tion if the above manipulations be followed out, but should such 
occur, complete relaxation of the quadriceps may be had under 
anesthesia. In old, unreduced dislocations of the patella reduction 
may be impossible by ordinary methods, and under such circum- 
stances it may be necessary to resort to open treatment. 

Operative Treatment. — Reduction of recent dislocations of the 
patella by the open method is rarely necessary. In old luxations 
and in instances of recurrent dislocations operative treatment is 
often the only method which will give satisfactory results. In 
either of these conditions the bone may be exposed by a vertical 
incision or by the usual U-shaped incision. In old luxations it may 
be necessary to break up old adhesions and cut through scar tissue 
before the bone can be returned to its original position. 

A number of methods have been advised and employed for the 



612 FRACTURES AND DISLOCATIONS 

correction of recurrent dislocations. The tubercle of the tibia, 
with its attached ligamentum patellae, may be chiseled off and re- 
attached to the tibia, internal to its original position, so that the 
pull of the quadriceps is straightened, and the muscle thus loses 
its outward displacing action on the patella. Another method con- 
sists in plication of the internal portion of the capsule or in the 
repair of a rent, if one exists, thus securing the inner border of 
the patella so that it cannot be displaced outward by the pull of 
the quadriceps. Still another method consists in increasing the 
prominence of the outer lip of the trochlea b}^ dividing it from 
the femur and displacing it forward. The first two methods are 
to be preferred to the last. In any of these operations the most 
strict asepsis is demanded, especially if the joint is opened. 

After-Treatment. — Following reduction, the knee should be put 
at rest on a ham splint, and measures instituted for the control of 
the traumatic arthritis. Snug bandaging, and the use of the ice 
cap will usually be followed by subsidence of swelling within a 
few days. "When the inflammatory reaction has passed, the knee 
should be strapped with surgeon's plaster to steadj^ the patella, 
and the patient should be cautioned to avoid unnecessary strains. 
The position of the knee in which the luxation occurred is particu- 
larly dangerous. 

Prognosis. — Dislocations, resulting from direct violence are likely 
to be followed by complete restoration of function, unless the 
trauma was severe and resulted in injury to the joint greater than 
that occurring in the ordinar}^ patellar luxation. Dislocations re- 
sulting from muscular action are likely to recur at some later date. 
Recurrent dislocations are usually followed by good results if ap- 
propriately operated. In old unreduced dislocations restoration of 
function may be delayed or incomplete as a result of articular 
changes occurring while the bone was displaced. 



CHAPTER XLIII. 

DISLOCATIONS OF THE KNEE. 

Surgical Anatomy. — In some of the lower animals the knee is 
composed of three distinct articulations. One between the outer 
tuberosity and the outer femoral condyle, another between the 
inner tibial tuberosity and the inner condyle of the femur and the 
third between the patella and the femur. In the human knee we 
have the analogues of these three joints although they are all 
merged into one. The crucial ligament attached to the inner con- 
dyle corresponds to the external lateral ligament of the inner articu- 
lation, and the crucial ligament attached to the outer condyle is 
analogous to the internal lateral ligament of the outer articulation. 
The knee-joint is the largest and one of the most complicated in 
the body. The proper apposition of the articular surfaces depends 
almost entirely on the ligaments holding the bones together, and 
when these structures are lacerated it will be necessary to allow 
sufficient time for them to become completely and firmly healed 
before the joint is subjected to any strain whatever. The liga- 
ments binding the tibia to the femur are the posterior ligament, the 
internal lateral, the external lateral (divided into two parts), the 
capsule and the crucial ligaments. The two lateral ligaments limit 
lateral motion when the knee is in the extended position but are 
much less effective in this respect when the knee is flexed. In 
the flexed position the crucials perform this function. The pos- 
terior ligament limits extension of the knee. The anterior liga- 
ment, however, does not limit the flexion of the joint since it has 
no attachment on the femur. It serves simply as the insertion of 
the quadriceps, the tonic action of which muscle, acting through 
the tendon, helps to keep the articular surfaces opposed in what- 
ever position the joint may be. The semilunar cartilages, and 
their ligaments (the coronary and transverse) are described under 
the heading of ''Fracture and Dislocations of the Semilunar Carti- 
lages, ' ' page 587. The ligamentum mucosum and alaria are simply 
reduplications in the synovial membrane and together with the 

613 



614 



FRACTURES AND DISLOCATIONS 



crucials represent the division of the joint into two lateral halves, 
previously referred to. The bones entering into the formation of 
the knee-joint are long, and hence the leverage exerted against 
the ligaments of the joint is considerable. The articular surfaces 
of the tibia and femur conform to each other only poorly and the 




Fig. 672. 



Fig. 673. 



Fig. 672. — Ligaments of the knee. I.L., Internal lateral ligament; E.L.. External 
lateral ligament; i'., Femur; T., Tibia; F. (below), Fibula; Con., Condyles. Between 
the two condyles may be seen the crucial ligaments. 

Fig. 673. — Ligaments of the knee. P.. Patella; I., Tibia; F., Fibula; L.P., Liga- 
mentum Patellae; T.T., Tibial Tuberde; C, Capsule. 



burden of holding these surfaces together rests entirely with the 
ligaments. The strength of these ligaments, however, is such that 
dislocations of the knee are extremely rare. It is more common for 
unusual strain to produce fracture than to tear the ligaments. 
Fracture produced in this way most often consists in the avulsion 



DISLOCATIONS OF THE KNEE 615 

of a small scale of bone corresponding to the insertion of the liga- 
ments onto the tnberosity of the femur or tibia, in some instances, 
however, an entire condyle may be broken off by the pull of the 
ligament. With the knees extended and the heels together, the 
legs are parallel, while the femora diverge to include the pelvis 
between them at their upper ends. It is apparent therefore that 
the axes of the tibia and femur are not in the same straight line. 
This lateral angle at the knee results in greater strain being thrown 
on the internal lateral ligament, when longitudinal compression 
stress is brought to bear on the lower extremity. Accordingly rup- 
ture of this ligament is more common than rupture of the external 
lateral ligament. If the ligament is torn between the femur and 
the semilunar cartilage, the cartilage will remain attached to the 
tibia, Avhich it will follow in displacement. If the tear is below 
the cartilage the reverse will be true. 

The most common dislocation occurring at the knee is so slight 
as to scarcely deserve the term of subluxation. It consists in a 
tearing of the internal lateral ligament so that the leg may be 
deviated outward and the inner condyle and tibial tuberosity may 
be separated a slight distance. Dislocations of the knee are classi- 
fied according to the direction taken by the tibia. Accordingly 
there are anterior, posterior, internal and external luxations of the 
knee. In addition there is another type of dislocation in which 
the tibia is rotated on the femur. 

The relation of the popliteal artery directly behind the articu- 
lation is of importance as already described under ''Fractures of 
the Lower End of the Femur." The popliteal nerve situated 
somewhat more superficially in the popliteal space, and the pero- 
neal nerve passing from behind the knee to the outer side of the 
leg where it winds around the head of the fibula, are sometimes 
injured in dislocations of the knee as evidenced by sensory and 
motor disturbances throughout their areas of distribution. 

The most important motion in the knee-joint is that of the hinge 
type. In addition to this there is a slight gliding action between 
the femoral condyles and the tibia, and when the knee is flexed 
there is a slight rotary motion between the two bones. The hinge 
action takes place between the femoral condyles and the semilunar 
cartilages, while the gliding and rotary motion is between these 
cartilages and the tibia. 

The antero-posterior luxations are more often incomplete than 



616 FRACTURES AND DISLOCATIONS 

complete. Complete lateral luxations of the knee are extremely 
rare. The most common luxation is forward, and then in order of 
frequency, backward, outward, inward and rotary. Great violence 
is necessary to produce luxation of the knee. Probably the most 
common injury to the knee-joint consists in rupture of the internal 
lateral ligament with temporary separation of the articular sur- 
faces on the inner side of the articulation. 

Symptoms. — The accident is almost invariably the result of severe 
trauma and if the history of the case is elicited an idea of the 
degree of violence applied to the lower extremity at the time of the 
accident can usually be had. Pain, shock and loss of function are 
usually pronounced. Any of the luxations occurring at the knee 
may be complete or incomplete, simple or compound and compli- 
cated or uncomplicated by injury to vessels and nerves. The 
symptoms will vary according to the details of the case. Abnormal 
mobility is present. In complete luxations the action at the knee 
is usually flail-like and the percentage of cases in which the con- 
dition is compound is high. In a complete forward dislocation of 
the knee treated by the author amputation was necessitated by the 
complete severance of the popliteal artery, and following the oper- 
ation the knee-joint was partially dissected for the purpose of ascer- 
taining the condition of the injured structures. The two lateral 
ligaments, the posterior ligament and the crucials were completely 
ruptured. The inner head of the gastrocnemius and the popliteus 
were torn across. The femoral condyles projected through a large 
rent in the popliteal space and their lower surfaces were about 
two and a half to three inches below the level of the tibial articular 
surfaces. The popliteal artery was completely torn across and the 
ends separated shortly above the popliteal notch. The popliteal 
and peroneal nerves were also completely divided. The semilunar 
cartilages remained with the tibia. This type of case is extreme 
and demands immediate amputation above the knee. 

It is more common to see an incomplete dislocation in which a 
portion of the femoral condyles remains in contact with the tibial 
articular surfaces. The loss of alignment in the axes of the femur 
and tibia is apparent. The forward displacement of the tibia is 
seen at a glance. The patella is less prominent than normal be- 
cause of the forward displacement of the tibia. If the artery is 
compressed or divided, loss of pulse and lowering of temperature 
below the knee will be noted. If the artery is simply compressed, 



DISLOCATIONS OF THE KNEE 617 

but not otherwise injured, the pulse will return with reduction of 
the luxation. Pain may be intense if the nerves are stretched or 
compressed ; if divided, sensory and motor paralyses will be present. 
In compound cases with laceration of the artery, hemorrhage is 
usually not profuse, strange as it may seem. 

In backward luxations the relations of the tibia and femur at 
the knee, are reversed. The lower end of the femur is prominent 
anteriorly while the posterior edge of the upper end of the tibia 
may be palpated posteriorly. If the luxation is complete the bones 
override in a manner similar to that described in the anterior form 
of luxation. The condition is much more likely to be compound 
when the luxation is complete. The femur may penetrate the skin 
anteriorly or the upper end of the tibia may be found projecting 
through a rent in the popliteal space. 

The lateral luxations usually consist of either inward or outward 
incomplete displacement of the tibia. Complete lateral luxation 
of the knee is quite rare and the complications accompanying the 
condition are usually less important than those occurring in the 
antero-posterior types. 

In the rotary form of luxation, which is extremely uncommon, 
the tibia is seen to have rotated on its axis so that the normal re- 
lations between the articular surfaces are disturbed. The rotation 
is seldom more than forty-five degrees and is more often outward 
than inward. The axis of rotation may pass through the outer or 
inner tuberosity or in the region of the tibial spine. The liga- 
mentous structures ruptured will depend largely on the axis of 
rotation. 

In the different luxations occurring at the knee any or all of the 
ligaments binding the tibia to the fibula may be ruptured or one of 
their attachments avulsed, according to the nature and degree of 
the dislocation. Avulsion of the tibial spine has occurred in lieu 
of rupture of the crucials. 

Traumatic reaction is usually pronounced during the first week 
or ten days following the accident. 

Function is completely lost in all forms of complete luxations of 
the knee. Active motion of the leg is sometimes only partially 
lost when the luxation is incomplete. 

Treatment. — Traction in the long axis of the lower extremity 
with coaptation pressure on the displaced articular ends will usually 
suffice to reduce the luxation. A fragment of bone such as that 



CHAPTER XLIV. 

INJURIES JUST BELOW THE KNEE— FRACTURES OF 
THE TIBIA AND FIBULA (UPPER ENDS). 

The injuries occurring in this region of the leg and to be con- 
sidered under this heading are: fracture of the upper end of the 
tibia (either into or below the knee-joint), separation of the upper 
tibial epiphysis, fracture of the upper end of the fibula, separation 
of the upper tibial epiphysis and dislocations of the upper tibio- 
fibular articulation. 

Surgical Anatomy. — The broad, expanded, upper extremity of the 
tibia which forms the tuberosities, is largely subcutaneous and can 
be readily palpated just below the plane of the knee-joint. The 
inner tuberosity presents a horizontal groove on its posterior aspect 
for the insertion of a portion of the semimembranosus. The cir- 
cumference of the tuberosity is taken up by the attachment of the 
capsule and the internal lateral ligament. In like manner the 
circumference of the outer tuberosity is taken up by the capsule on 
the outer side of the joint, but the external lateral ligaments of the 
knee are not attached to this bone but to the head of the fibula. 
The posterior aspect of the outer tuberosity articulates with the 
upper end of the fibula, and half-way between the tibial tubercle 
and the fibular head is inserted the lower end of the ilio-tibial 
band. The upper end of the tibia is composed of cancellous tissue 
which is encased in a thin layer of compact bone. The heavy 
compact tissue of the shaft grows rapidly thinner as the upper end 
of the bone is approached. 

Fracture of the upper end of the tibia is the result of direct or 
indirect violence, usually the former. The line of fracture may 
be vertical, entering the joint cavity, or it may be transverse and 
below the articulation. Transverse fracture of the upper end of 
the tibia is usually the result of direct violence and the displace- 
ment is, as a rule, not great. The superficial position of the bone 
accounts for the frequency of compound fractures in this region, 
especially when produced by direct violence. When the fracture 

620 



INJURIES JUST BELOW THE KNEE 621 

enters the joint it is usnally the resnlt of violent adduction or 
abduction of the leg. T-fractures however are usually the result 
of violence transmitted to the upper end of the bone in the long 
axis of the tibia. When this mechanism obtains in the production 
of fracture of the upper end of the tibia the shaft is driven upward 
into the upper fragment and usually splits it into two or more 
pieces. The upper fragment is sometimes extensively comminuted. 
This type of fracture is most frecpiently the result of a fall from 




Fig. 674. — Lateral view of the knee before the epiphyses have joined the shaft. 
Note how the iipper epiphysis of the tibia extends downward anteriorly to include the 
tubercle of the tibia. This formation is spoken of as the "lipping" of the upper tibial 
epiphysis. 

a height in which the patient lands on the foot. In rare instances 
the shaft may be driven upward into the upper fragment without 
splitting the latter and the result is likely to be impaction with 
shortening of the leg, but no abnormal mobility, crepitus, etc. 
Most of the fractures of the upper end of the tibia entering the 
joint cavity are accompanied by spreading of the tuberosities. The 
action of the lateral ligaments in producing fracture of the tuber- 
osities or of the femoral condyles has been described under "Dislo- 
cations of the Knee," and again under ''Fractures of the Lower 



622 



FRACTURES AND DISLOCATIONS 



End of the Femur." Fracture and avulsion of the spine of the 
tibia due to the pull of the crucials is a complication of disloca- 
tions of the knee, and has been mentioned under that heading. 

The upper epiplwsis of the tibia is ossified from a single center 
which makes its appearance soon after birth and joins the shaft 
at about the twentieth year. The epiphyseal cartilage corresponds 
roughly to a horizontal plane about one inch below the top of the 
bone. Anteriorly however it dips downward as it approaches the 
anterior border, to pass under the tibial tubercle. A not uncom- 
mon anomaly is for the tibial tubercle to be ossified by a separate 




Fig. 676. 



Figs. 675 and 676. — An anomaly in the ossification of the upper end of the tibia 
which is likely to be mistaken for fracture of the tibia. A close examination of an 
X-ray plate (not print) will show the supposed fragment to be surrounded by a layer 
of compact tissue and the contour of ossicle does not correspond to the portion of the 
tibia from which it is supposed to have been broken off. Moreoyer this type of anomaly 
is almost invariably bilateral. 



center. This downward extension of the epiphysis to include the 
tibial tubercle is of importance clinically. The quadriceps extensor 
is attached to the tubercle through the ligamentum patellae, and 
with violent contraction of this muscle the anterior part of the 
epiphysis (the tubercle of the tibia) may be partially or completely 
separated from the diaphysis. Complete separation of the tibial 
epiphysis is an extremely rare condition but a starting of the 
tubercle with a corresponding partial detachment of the epiphj^sis 
is not uncommon in youth. 

The upper extremity of the fibula does not enter into the forma- 



INJURIES JUST BELOW THE KNEE 



623 




Fig. 677 



Fig. 677. — Vertical fracture of upper end of tibia. 
Fig. 6 7 8. -^Vertical fracture of upper end of tibia. 



Fig. 67J 




679 



680. 



Fig. 679. — Fracture of upper end of tibia involving the external articular surface. 

Fig. 680. — Splitting of upper end of tibia. 

Vertical fractures of the upper end of the tibia such as those shown on this page are 
not uncommon, and if not accurately reduced considerable disturbance in joint function 
may result. Operative measures are frequently indicated to obtain the best results. 



624 FRACTURES AND DISLOCATIONS 

tion of the knee-joint, thoug-h the two external lateral ligaments of 
the knee are attached to it. The long head of the biceps (outer 
hamstring muscle) is inserted around the base of the styloid 
process, and the attachments of the soleus, peroneus longus and 
extensor longus dig^itorum are continued upward from the shaft 
onto the upper extremity of the bone. This epiphysis of the fibula 
begins to ossify about the fourth jeRr and joins the shaft at about 
the twenty-fifth. Violent contraction of the biceps is known to 
have caused fracture of the upper end of the fibula, or separation 
of the epiphysis, and adduction of the leg has produced the same 
result through the pull of the external lateral ligaments. Fracture 
of the upper end of the fibula just below the head of the bone is 
usually the result of direct violence. Occasionally it accompanies 
fracture of the upper end of the tibia. 

The upper tibio-fibular articulation is a simple arthrodial joint 
with very limited motion. The articular surfaces entering into its 
formation are flat and the integrity of the joint depends entirely 
on the strength of the ligaments holding the two bones together. 
This joint possesses an anterior and a posterior ligament which are 
thickenings in the capsule surrounding the articulation. Anterior 
and posterior displacements are prevented as long as the force is 
not sufficient to rupture these ligaments. Upward displacement 
is prevented not only by these ligaments but by the interosseous 
membrane and the lower tibio-fibular articulation. The importance 
of displacements of the upper end of the fibula depends mainly on 
the fact that the peroneal nerve winds around the neck of the 
bone and may be injured with direct violence to the outer side of 
the leg, or when the head of the fibula is luxated. This nerve can 
be felt beneath the skin behind the tendon of the biceps. It 
passes between the tendon of the biceps and the outer head of the 
gastrocnemius and then winds around the neck of the fibula. It 
passes forward to join the anterior tibial artery and gives off 
branches, as it passes down the front of the leg, to supply the 
extensors of the foot. Injury to this nerve is accompanied by foot 
drop. 

Etiology.- — Fractures of the upper ends of the tibia and fibula are 
usually due to direct violence. Forcible adduction or abduction 
of the leg may result in fracture of the tuberosities. A^iolence 
transmitted in the axis of the leg may produce fracture of the 
upper end of the tibia and fibula, although all forms of indirect 



INJURIES JUST BELOW THE KNEE 625 

violence are more likely to produce fracture below the middle of 
the shaft. 

Symptoms. — Because of the variety of fractures which occur in 
this region, the symptoms seen in different cases vary considerably. 
The swelling and deformitj^ which accompany simple transverse 
fracture of the upper end of the tibia may be remarkably slight. 
I have seen a number of cases suffering from this type of fracture 
in which the patient was able to bear weight on the leg. The dis- 
ability, however, is usually complete. Abnormal mobility is almost 
invariably present although impaction of the lower, into the upper 
fragment, may result in the leg being quite firm. When the frac- 
ture is of the T-type or in instances in w^hich one of the tuberosities 




Fig. 681. — Fracture of upper end of tibia. Note thickening at point indicated by arrow. 

is broken off, articular distention and traumatic arthritis develop 
rapidly. Under these circumstances the lateral stability of the 
knee is usually lost and abnormal lateral mobility is apparent as 
soon as the parts are manipulated. The leg may be adducted or 
abducted to an abnormal degree and this maneuver usually pro- 
duces crepitus. In T-fracture of the upper end of the tibia or in 
fracture of one of the tuberosities, the tuberosities may be spread 
to such an extent that the condition is readily recognized by 
inspection alone. (See Figs. 681 and 682.) The parts below the 
knee are tender and painful. Fracture in this region, due to direct 



626 FRACTURES AND DISLOCATIONS 

violence, is often compound and if the line of fracture enters the 
joint it may be followed by suppurative arthritis. 

Avulsion of the tubercle of the tibia is accompanied by a more or 
less upward displacement of the patella according to the extent of 
tearing in the lateral expansions of the aponeurosis of the quadri- 
ceps extensor. The loose detached fragment can be palpated 
without difficulty unless the swelling is intense. The ligamentum 
patellae is abnormally lax. Rupture of the patellar ligament gives 




Fig. 682. — Longitudinal fracture of the upper end of the right tibia. Tuberosities 
spread so that finger may be pressed into external articular cavity just above prominence 
indicated by arrow. Such a fracture will interfere with the use of the knee-joint unless 
the fragments are brought together and held in place. Operation is usually necessary 
in this type of case to secure the best results. 

a similar symptom-complex except for the absence of the detached 
fragment of the tubercle. 

Separation of the upper tibial epiphysis is attended by symptoms 
similar to fracture in this region. The epiphysis may be displaced 
in any direction. The crepitus produced by manipulation is soft 
and cartilaginous. The condition is extremely rare. 

Fracture or epiphyseal separation of the upper end of the fibula 
is accompanied by local tenderness and pain especially when the 
leg is used. It is often possible to move the head of the bone about. 
Crepitus is usually elicited without difficulty. If the fracture is 



INJURIES JUST BELOW THE KNEE 627 

tlirough the tibio-fibnlar articulation or below it, pressure on the 
shaft of the bone, in the middle of the leg, will produce pain at the 
seat of fracture. Injur}^ to the peroneal nerve will be productive 
of characteristic symptoms in motion and sensation throughout the 
distribution of the nerve. In luxations of the fibular head the 
upper end of the bone is more prominent than normal and its dis- 
placement either forward or backward is, as a rule, easily recog- 
nized. 

Injuries to vessels and nerves are not as common in this region 
of the leg as they are in fractures of the lower end of the femur but 
when they do occur the same train of symptoms will become mani- 
fest. 

Diagnosis. — There is, as a rule, little difficulty in recognizing 
fracture in this region. A simple transverse break, however, just 
below the tibial tuberosities, may, in rare instances, be difficult 
to determine without the aid of the X-ray. In the exceptional 
cases in which the shaft is impacted into the upper fragment with- 
out splitting the latter, abnormal mobility may be absent, but the 
condition should be recognized by the shortening of the leg, and 
in some instances there W'ill be sufficient angular deformity to indi- 
cate the nature of the lesion. The X-ray is of the greatest value 
in determining the nature of the injury in the exceptional cases 
in which the physical signs are indefinite. 

When the upper end of the fibula alone is fractured the patient 
may be able to get about, though the use of the member entails more 
or less swelling and pain. This fracture has not infrequently been 
overlooked in spite of the fact that pressure in the middle of the 
shaft is productive of pain at the site of the lesion, if the fracture is 
below or through the upper tibio-fibular articulation. If the frac- 
ture is above this level it should be recognized by direct palpation. 

Treatment. — The desiderata in the treatment of these fractures 
are : reduction of deformity, immobilization of the fragments and 
restoration of function after the fragments have united. The 
details of treatment will vary with the type and severity of the 
fracture. In a simple transverse fracture of the upper end of 
the tibia, deformity is often slight and reduction easy. Strong 
traction on the leg with direct pressure over the displaced frag- 
ment will usually effect reduction. The fragments, however, are 
often so well apposed that nothing in the way of treatment is indi- 
cated aside from fixation. The lower extremity should be immo- 



628 FRACTURES AND DISLOCATIONS 

bilized on a long posterior splint extending from just above the 
heel to a point a short distance below the buttock. The regulation 
ham splint may be used or one may be made of plaster. The knee 
should be fixed in a position just short of complete extension and 
the padding employed should be so disposed as to evenly and firmly 
support the lower extremity throughout the length of the splint. 
If there is any tendency for the foot to be rotated inward or out- 
ward the splint should include the foot. This may be accomplished 
by a posterior plaster splint extending downward to include the 
heel and sole of the foot. The same result may be had by means 
of a long plaster stirrup extending well up onto the thigh, or the 
long side T-splint, similar to that used in fractures of the hip, may 
be employed. Whichever splint is used the means of securing it in 
position will be found in adhesive strips and bandages. In cases 
in which the traumatic reaction is severe, and rapid in onset, it 
may be advisable to postpone manipulation of the parts until it has 
subsided. This is particularly true when the fracture has entered 
the knee-joint with the development of a traumatic arthritis. 
When the fracture enters the joint cavity the correction of deform- 
ity and maintenance of the fragments in proper reduction is usually 
much more difficult than in simple transverse fracture. In a 
T-fracture, or breaking otf of one of the tuberosities, an attempt 
should be made to force the fractured surfaces together so that 
the articular surfaces on the head of the tibia will be in proper 
relation with the condyles of the femur. This is often a difficult 
matter and requires skillful manipulation. If one of the tuber- 
osities has been broken off, lateral deviation of the leg to the 
opposite side will often facilitate reduction of the displaced frag- 
ment. If the fracture is of the T-type with separation of the 
tuberosities, adduction or abduction of the leg will accomplish 
nothing. Under these circumstances strong traction in the axis of 
the tibia will be necessary while the tuberosities are forced 
together by lateral pressure. In some cases it will be impossible to 
approximate the tuberosities in this manner, and in other instances 
the tendency to recurrence" of deformity may be so great that the 
tuberosities separate as soon as traction and lateral pressure are 
removed. Under these circumstances open reduction either with 
or without internal fixation is indicated. Not infrequently a 
loose fragment of bone between the tuberosities acts as an obstacle 
to reduction and will require removal before the fragments can 



INJURIES JUST BELOW THE KNEE 629 

be broug-lit into proper position. In instances in which the shaft 
has been driven into the upper end of the tibia with extensive 
comminution, the destruction of bone may be so great that it is 
impossible to restore the original contour of the upper extremity 
of the bone. In this type of case continuous traction by means 
of Buck's extension will often accomplish more than any other 
method. AYhen extension is employed for this purpose the lower 
extremity should be so fixed to the splint that the traction does not 
pull the axes of the tibia and fibula into the same straight line, 
otherwise the normal lateral angle of the knee will be obliterated. 

AYhat has been said of the treatment of fracture of the upper 
end of the tibia applies equally well in separation of the upper 
tibial epiphysis. 

Avulsion of the tibial tubercle in the adult usually calls for 
operative treatment to secure the fragment in proper position. 
Straps of adhesive above the patella to prevent upward displace- 
ment, and bandages about the upper part of the leg to force the 
fragment home are, as a rule, only partially successful. If there 
has been little or no upward displacement of the fragment non- 
operative measures will probably produce the desired result. 
Starting of the tubercle as an epiphysis is usually not attended by 
much displacement and the treatment will consist of fixation and 
rest until the loosened portion of the epiphysis has become firmly 
fixed again. 

In luxations of the head of the fibula, pads may be so placed, and 
held in position by straps of adhesive plaster, as to prevent recur- 
rence of deformity. The lower extremity should be immobilized 
for three or four weeks, and in backward luxations the condition 
should be treated with the knee semiflexed to relax the pull of the 
biceps. If these measures are not etfective in maintaining reduc- 
tion, or if evidences of nerve laceration are present, operation is 
indicated. Operation is also indicated in fractures of the fibular 
head with upward displacement of the fragment. 

Operative Treatment. — In cases of simple transverse fracture of 
the tibia below the knee, with good reduction, operative interven- 
tion offers nothing, but when the fracture enters the joint cavity it 
may become necessary to cut down on the fragments to restore the 
articular surfaces of the knee-joint to their normal relations. 
Cases in which the tuberosities cannot otherwise be brought back 
into proper relation, or in which recurrence of deformitv takes 



630 FRACTURES AND DISLOCATIONS 

place, should be operated upon. If two longitudinal incisions are 
made, one on the inner and the other on the outer side of the joint, 
the fragments may be directly manipulated and reduction effected. 
If a solid engagement can be obtained between them, the incisions 
may be closed and splints applied. If a tendency toward the 
recurrence of deformity is manifest the fragments should be 
secured by some method of internal fixation. Non-absorbable 
materials should not be used if the fracture is compound. In a 
number of cases of T-fractures the author has found the following 
procedure satisfactory: two holes are drilled transversely through 
the tuberosities after they have been forced together, and a heavy 
silver wire is threaded through the holes and the ends tightly twisted 
together, thus maintaining the fragments in proper position and 
restoring the intra-articular surfaces .in their normal relations. 
This method is equally efficient in instances in which one of the 
condyles is broken off' and displaced. The principle is the same as 
that already described as ''transverse wiring" under the heading 
of '^Operative Treatment of the Lower End of the Femur." Nails, 
screws, and the Lane plate are at a discount in this region because 
of the internal structure of the upper end of the tibia which is 
composed of a loose cancellous tissue. Compound fractures of the 
upper end of the tibia should be treated according to the principles 
laid down under the heading of '"The Treatment of Compound 
Fractures" on page 789. 

Avulsion of the tibial tubercle with displacement of the frag- 
ment can seldom be reduced and maintained in proper position 
without operation. The fragment may be secured in place by 
means of a small nail or it may be sutured to the adjacent peri- 
osteum and surrounding soft tissues with absorbable suture material. 
Probably the best method in the adult, is to secure it to the shaft by 
means of a loop of silver wire. The scale of bone torn away may 
be too small to fix in this manner, or instead of an avulsion there 
may be a rupture of the patellar ligament, and when either of these 
conditions is encountered, the operation must consist of suturing 
of the soft tissues to properly anchor the ligament. When the 
tubercle is a\ailsed as an epiphysis it should not be sutured in 
position with anything except absorbable material. 

An occasion calling for open reduction of a complete separation 
of the upper tibial epiphysis almost never arises. In fractures or 
dislocations of the upper end of the fibula, the condition most often 



INJURIES JUST BELOW THE KNEE 631 

rendering operation necessary, is injury to the peroneal nerve as it 
winds around the neck of the bone. When a portion of the fibular 
head has been displaced upward by the pull of the biceps, the 
fragment should be exposed, replaced and sutured in position. 
Non-operative methods of correcting this displacement are usually 
not successful. 

In dislocations of the head of the fibula the most prompt recovery 
and complete restoration of function follow open reduction, with 
fixation of the head in proper position against the external tibial 
tuberosity. This may be accomplished by suturing the soft tissues 
about the head or by means of a single loop of wire passed through 
the adjacent portion of the tuberosity. 

After-Treatment. — The first portion of the after-treatment will 
depend largely on the intensity of the traumatic reaction following 
the injury and whether or not the knee-joint is involved. When 
the reaction is severe it is often best to postpone manipulation of 
the parts until it has subsided. The lower extremity should be 
treated on a pillow-splint and the member elevated to favor circu- 
lation. The ice cap will aid materially in controlling the swelling. 
Undue constriction of the member should be avoided. With the 
subsidence of swelling, reduction should be accomplished by non- 
operative methods, if possible, or with operation if necessary. At 
the end of ten days or two weeks a permanent dressing should be 
applied. The plaster cast or plaster splints will be found quite 
satisfactory in this respect. If the plaster cast is used it should be 
split up the front before the plaster has set so that it may be 
removed during the after-treatment for inspection, massage and 
passive motion of the leg. Repeated adjustments will be found 
necessary during the after-treatment to keep the patient comfort- 
able. Frequent inspection of the leg is necessary to recognize and 
treat pressure points on the skin, should they develop. In the 
healthy adult union is to be expected in an uncomplicated case at 
the end of six weeks, but the callus at this time is too soft to with- 
stand any considerable strain. The full weight should not be 
borne on the leg for another month. Gratifying results have been 
obtained by use of the ambulatory pneumatic splint in simple frac- 
tures of this region. When this splint is employed it is often 
possible to begin the ambulatory treatment as soon as the acute 
swelling has subsided. In compound fractures of the upper end 
of the tibia recovery may be much delayed by the development of 



632 FRACTURES AND DISLOCATIONS 

necrotic bone or arthritis of the knee. Persistent discharging 
sinuses call for operation to remove the dead bone. Early guarded 
passive motion will accomplish a great deal in the prevention of 
permanent adhesions within the joint cavity. Anesthesia and 
forcible passive motion may be indicated to break up organized 
adhesions within the knee. Even arthrotomy may be called for in 
instances in which the adhesions are unusually strong. Early 
passive motion is called for to restore the function of the knee but 
the greatest care should be exercised to avoid refracture during 
the time the callus is friable. If a firm grasp be taken of 
the upper end of the tibia, force may be applied with much less 
risk than is the case when the leg is moved by the- usual grip above 
the ankle. The lower the leg is grasped, in performing passive 
motion, the less the surgeon appreciates the leverage he is exerting 
against the upper end of the bone and the articulation. The dress- 
ing should be renewed from time to time to accommodate the 
changes which occur with the onset and subsidence of swelling. 
The older the patient the longer the time required for firm union 
to take place and the more imperfect recovery will be in the end. 

In avulsion of the tubercle of the tibia union may be expected 
within six weeks and the member may be actively used at the end 
of two and a half months. If the condition has been treated by 
non-operative methods the parts should be frequently inspected to 
see that the strappings are properly performing their function in 
holding the fragment in reduction. 

In separation of the upper tibial epiphysis the knee should be 
immobilized for a period of six weeks during the latter half of 
which time passive motion should be performed at intervals of 
four or five days. 

In dislocations of the upper end of the fibula retentive apparatus 
should be kept in place for about a month, provided the luxation 
has not been secured in position by operation and internal fixation. 
During this time undue strain should be avoided, especially activ- 
ities which involve forceful contraction of the flexors of the leg of 
which the biceps is one. 

Prognosis. — The prognosis of fractures of the upper end of the 
tibia is very variable according to the extent and severity of the 
lesion. Simple fractures not produced hy severe trauma are 
usually followed by complete restoration of function. On the other 
hand, a severe compound fracture entering the knee-joint may be 



INJURIES JUST BELOW THE KNEE 633 

followed by infection of the knee-joint with septicemia and death. 
Restoration of function in severe cases is usually prolonged and 
seldom complete. The development of septic arthritis renders the 
fracture itself only of secondary importance. The prognosis fol- 
lowing operative cases is better than those treated by non-operative 
methods. Union often takes place with permanent thickening 
below the knee and the motion in the articulation is not infrequently 
restricted. 

The prognosis of avulsion of the tubercle of the tibia in the adult 
is good with proper treatment; when separated as an epiphysis 
the prognosis is equally good. 

The prognosis of fractures and dislocations of the upper end of 
the fibula is good, aside from the injuries sustained by the peroneal 
nerve. When the nerve is injured the outlook varies with the 
degree of the injury and the completeness of repair which is pos- 
sible at operation. 



CHAPTER XLV. 

FRACTURES OF THE SHAFTS OF THE BONES 
OF THE LEG. 

The division of fractures of the leg into : Fractures of the upper 
ends, Fractures of the shafts and Fractures of the lower ends, is 
not a scientific classification of these injuries, yet it forms a work- 
ing basis for their consideration. There is no hard and fast line 
to be drawn between fractures of the shaft and fractures of the 
extremities. The nearer the break is located to the end of the 
bone the more it assumes the characteristics of a typical fracture 
of the extremity. 

Surgical Anatomy. — The shafts of the bones of the leg are each 
ossified from centers which make their appearances during the 
seventh and eighth weeks of foetal life. That for the tibial shaft 
delevops first. The shaft of the tibia constitutes the main strength 
of the leg. It is distinctly triangular in cross-section and shows 
three surfaces separated from each other by three prominent 
borders. The anterior border is subcutaneous and may be palpated 
from the tibial tubercle to the internal malleolus. The lower third 
of this border, however, is much less prominent, and is more or less 
obscured by the tendon of the tibialis anticus. The external border 
is directed toward the fibula and has attached to it the heavy 
interosseous membrane. The internal border may be palpated 
throughout, though in well developed persons the middle portion 
is more or less encroached upon by the bellies of the flexor muscles 
of the foot. The internal surface of the bone is subcutaneous except 
for the insertions of the gracilis, semitendonosus and sartorius, 
which are attached to the upper end, a short distance below^ the 
inner tuberosity. AVith the intense swelling, which so frequently 
develops following fracture, it is hard to realize that this portion oi: 
the bone is subcutaneous. The thickening is often sufficient to 
obscure the outline and render palpation difficult, but it should 
be remembered that this infiltration is in the subcutaneous tissues 
and that gentle, firm and continued pressure, with the finger tips, 

634 



FRACTURES OF SHAFTS OF THE BONES OF LEG 635 

will SO displace these fluids that the condition of the bone may be 
recognized. 

The weakest part of the tibial shaft is at, and just below, the 
junction of the middle and lower thirds, and it is here that fracture 
most frequently occurs. The shaft is composed of a tube of heavj^ 
compact tissue and the fractures occurring in this region are clean 
cut and show no impaction or crushing of bone tissue. Comminu- 
tion is not infrequenth^ seen and the fracture may be multiple ; 
but the fragments are hard and the edges clean cut, and screws find 
a firm foothold when the Lane plate is employed to secure reduc- 
tion and immobilization. The shaft of the tibia normally bows 
slightly forward while the fibula bows a little in the opposite direc- 
tion. 

The shaft of the fibula is almost entirely surrounded by muscles 
which act as cushions in the presence of direct violence. The upper 
extremity and external malleolus are the only portions of the 
fibula which can be satisfactorily palpated. The lower third or 
fourth of the external surface of the bone may be felt between 
the peroneus tertius anteriorly and the peroneus longus and brevis 
posteriorly. The shaft of the fibula is long and slender and nor- 
mally possesses a certain degree of spring when compressed against 
the tibia. This fact is of importance clinically since lateral pres- 
sure, in the presence of fracture, will detect an increase or loss of 
this spring as compared with the opposite fibula, even though the 
bone cannot be directly palpated. 

The shafts of the bones of the leg are usually both broken, 
though isolated fracture of either bone may occur. The fibula is 
more frequently fractured than the tibia. When both bones are 
broken the lesion in the fibula is usually at the higher level. The 
fracture in the tibia may be transverse, oblique, spiral, or longi- 
tudinal. Spiral and oblique fractures are quite common below the 
middle of the shaft and are usually the result of indirect violence. 
Transverse fractures are more common above the middle of the 
shaft and are usually due to direct violence. 

The upper posterior portions of the shafts of the bones of the 
leg are covered and protected by the heavy calf muscles, and the 
tendo Achillis in the lower part of the leg is capable of breaking 
the force of a blow, when direct violence is sustained from behind. 
Anteriorly the tibia has no such protection but receives the full 
force of direct violence applied to the shin. 



636 



FRACTURES AND DISLOCATIONS 




Fig. 683. — Compound fracture of both bones of the leg. Note the eversion of the 
foot and compare it with the patella which is directed upward. 




Fig. P84. — Fracture of both bones of the leg in their lower thirds. Nute the flai 
like condition. 




Fig. 68.5. — Compound fracture of both bones of the leg with shortening and ever- 
sion. Result of direct violence. Note the position of the patella which looks directly 
upward while the foot is decidedly everted. Lower end of upper fragment penetrated 
the skin where the wound is seen at "x," 



FRACTURES OF SHAFTS OF THE BONES OF LEG 



637 



The snbcutaneous position of the anterior border and internal 
surface of the tibia accounts for the large proportion of compound 
fractures in this region, especially when caused by direct violence. 
The direction of the oblique or spiral fracture is usually from 
above, downward and forward. 

Etiology. — Fracture of the shafts of the bones of the leg is 
rather a common accident and results from either direct or indirect 




Fig. 



Figs. 686 and 687. — Show a simple fracture of both bones of the leg in their lower 
thirds. Note the inward falling of the foot, while the position of the knee is normal. 
Photographs taken a few minutes following injury. 



violence. It is often caused by a twist of the leg, a fall from a 
height, a direct blow on the shin, or a crushing force, such as being 
run over by a wagon. Fractures of the fibula alone are usually the 
result of direct violence. Fracture of the tibia alone is almost 
always the result of direct violence. Fracture of the shafts of 
these bones occurs most frequently during the fourth, fifth and 
sixth decades. This accident is the most frequent, occurring in the 



638 



FRACTURES AND DISLOCATIONS 



lower extremity, and constitutes approximately six percent of all 
fractures. 

Symptoms. — Immediate and total loss of function is the rule. 




Fig. 



Figs. 6SS and 689. — Fracture of both hones of the leg near junction of lower and 
middle thirds, seen a few minutes after the accident and again four days later. Note 
the position of the patella looking directly upward while the foot has fallen inward of its 
own weight. Condition flail-like. In Fig. 689 (same leg four days later) the deform- 
ity has been corrected and the sides of the fracture box, in which the leg has been 
placed, have been let down for inspection of the parts and readjustment of the padding. 
Note the swelling of the leg and the development of blood-blebs over the site of fracture. 
The leg is the most common site for the development of these blood-blebs following frac- 
ture. The leg should not be put in a permanent dressing until the denuded surfaces 
resulting from these blebs have thoroughly healed. 



Pain, crepitus, abnormal mobility and deformity are almost uni- 
formly present. The deformity is usually sufficient for the surgeon 
to recognize the condition by inspection alone. Fracture at the 



FRACTURES OF SHAFTS OF THE BONES OF LEG 639 

usual site (^uear the junction of the lower and middle thirds) com- 
monly shows a downward and forward displacement of the lower 
end of the upper fragment with a corresponding upward and back- 
ward displacement of the lower fragment. The leg is usually flail- 
like and the foot falls either inward or outward (usually the latter), 
according to the position in which the lower extremity happens to 




Fig. 690. — Green-stick fracture of the tibia in a child a few minutes following the 
injury. Note the slight inward bowing of the skin. In this case it was possible to 
slightly spring the tibia inward by lateral pressure. Arrow indicates site of fracture. 




Fig. 691. — Double compound fracture of both bones of the leg. Note the position of 
the patella, as outlined through the bandages, and the relation it bears to the foot which 
is everted and displaced posteriorly. Leg below the fracture is flail-like permitting of 
displacement in any direction. Extensive injury to soft tissues. The tibia and fibula 
(upper fragments) penetrated the skin through the wound on the outer side of the leg 
as indicated by "X" in plate. The blood on the towel is coming from this wound. In- 
jury produced by heavy wagon loaded with three tons of coal passing over leg. 

be placed. "When both bones are broken, abnormal mobility is much 
greater than when the tibia alone is fractured. It is not uncom- 
mon to see the end of either the upper or lower tibial fragment pro- 
jecting through the skin on the anterior aspect of the leg. 

Fracture of the fibula alone is not attended by much loss of func- 
tion unless the break is close to the ankle, and even then the author 
has seen cases in which the patient was able to walk, in spite of 



640 



FRACTURES AND DISLOCATIONS 



the injury. Pain occurs with use of the limb and pressure on the 
shaft of the bone will produce pain at the site of the lesion even 
though the pressure be made above or below^ the level of fracture. 
Fracture of the fibula near the ankle may disturb the mortice of the 
ankle joint by an outward displacement of the external malleolus 
as the upper end of the lower fragment is displaced toward the 
tibia. 




Fig. 692. 




Fig. 693. 

Figs. 692 and 693. — Two views of an oblique fracture of the tibia a few inches 
above the ankle. The displacement is very slight between the tibial fragments. The line 
of the fracture can be recognized only by careful palpation. This almost complete absence 
of deformity is due to the fact that the fibula remains intact and acts as a splint for the 
broken tibia. Photogi'aph about twelve hours following the accident. Arrow indicates 
position of fracture. 



Fracture of the bones of the leg is usually attended by severe 
traumatic reaction within a few hours of the accident. Swelling is 
pronounced and ecchymosis develops in the region of the fracture 
during the first twenty-four to forty-eight hours. It is not uncom- 
mon for blebs to form in the skin at any time during the first week 
and their contents may be either blood or serum or a mixture of 
these two materials (see Fig. 689). In fractures of this type the 
injury to the soft tissues may be so great that the fracture itself is 



FRACTURES OF SHAFTS OF THE BONES OF LEG 



641 



only of secondary importance. If the fibula remains intact 
abnormal mobility will usually not be as pronounced as when both 
bones are broken. Green-stick fracture of the tibia sometimes 
occurs in children and may be accompanied by such slight preter- 
natural mobility as to render recognition difficult (see Fig. 690). 
]\Icst fractures of the leg are accompanied by severe traumatic reac- 




Fiff. 694. 




Fig. G95.. 

Fies. 694 and 695. — Severe compound, comminuted fracture of the bones of the leg. 
Hemorrhage free. Numerous globules of fat could be seen in the blood as it flowed from 
the wound having escaped from the tissues of the medullary cavity. These globules of 
fat in the blood remind one of the cases of fat embolism sometimes encountered in frac- 
tures. The lower plate (Fig. 695) is a closer view of the same case after the blood 
has been sponged away so the fragments of the tibia may be seen. 



tion but occasionally a case is seen in which the causative trauma 
has been just sufficient to produce the fracture and the resultant 
swelling and inflammation are slight. In fractures produced by 
great trauma the skin covering the tibia may be extensivel.y torn 
and loose fragments of bone may be seen lying in the wound. In 
rare instances the circulation below the fracture may be destroyed 
so that no pulse can be detected in the dorsalis pedis, the foot be- 



642 



FRACTURES AND DISLOCATIONS 



comes cold and lifeless and is later followed by gangrene. Symp- 
toms of nerve injury are rare. 

Diagnosis. — The symptoms are, as a rule, pronounced and there 
is little difficulty in recognizing the fracture. The deformity is 
usually so characteristic that a diagnosis can be made by inspection 
alone. The details of the fracture, however, are often impossible 




697. 



Figs. 696 and 697. — Severe, compound fracture of the tibia and fibula in their 
upper thirds. Upper end of lower tibial fragment is displaced upward and outward and 
lies just under cover of the skin. Extreme laceration and damage to the soft tissues. 
It is this type of fracture Avhich usually requires amputation. The opening in the 
skin is the result of trauma at the time of the accident. Note the flail-like attitude of 
the leg below the fracture. 



to determine without the aid of the X-ray. Isolated fracture of 
the fibula may go unrecognized unless a careful examination is 
made. The significant fact, when the fibular shaft alone is frac- 
tured, is that pressure on the shaft of the bone produces pain at 
the site of the break rather than at the point of pressure. 

Treatment. — The emergency treatment of fractures of the leg is 
of considerable importance. Some form of temporary splint should 



FRACTURES OF SHAFTS OF THE BONES OF LEG 



643 



be employed in transporting the patient from the scene of the 
accident to the hospital or home. The greatest care should be exer- 
cised to avoid converting a simple fracture into a compound one. 






■^Pr 



\ 



I 



^ 



:. 698. — Folding fracture-box laid open. 



Fig. 699. — Same closed. 



This may be easily done as the patient is being moved, or during 
careless manipulation of the leg. The less the parts are disturbed 
at this time the less pronounced will be the traumatic reaction, dur- 
ing the following week. 




r\ 


B 















Fig. 700. — (A) Padding- in fracture-box to conform to the posterior aspect of the 
leg. (i?) Fracture-box closed and sides held in position with three strips of adhesive 
plaster. 



In the reduction of fractures of the leg an anesthetic should be 
employed to relieve the pain and overcome muscular spasm. If 
the foot is grasped above the ankle and strong traction exerted 



644 



FRACTURES AND DISLOCATIONS 



while an assistant makes counter-traction just below the knee, it 
will usually be possible to return the fragments to their proper 
relations without great difficulty. Coaptation pressure on the frag- 
ments may be necessary and in transverse fractures angulation of 
the leg at the seat of the break may be required before an engage- 
ment of the fractured surfaces can be had. Pressure should not be 
made directly over the prominent end of a fragment lest the condi- 
tion be rendered compound by penetration of the skin from within. 
It is common in spiral and oblique fractures to see recurrence of 




Figs. 701 and 702. — Leg is seen in fracture-ljox with proper padding in place and 
side of box let down for inspection and readjustment of dressings, and again with 
fracture-box closed and fastened. 



deformity take place as soon as the foot is released, and it is this 
type of break which most needs operative treatment and internal 
fixation. 

The treatment of fractures of the leg varies according to the 
amount of trauma and laceration sustained by the soft tissues and 
the facility with which the fragments can be held in reduction. 
During the first week or ten days the leg should be immobilized in 
some form of temporary splint which will steady the parts and yet 
allow perfectly for frequent inspection and adjustments, during 
the onset and subsidence of swelling. A number of appliances, 



FRACTURES OF SHAFTS OF THE BONES OF LEG 



645 



varving in detail, though the same in principle, have been employed 
dnring- this period for the temporary treatment of fractures of the 
leg. The fractnre-box, pillow splint, posterior gutter splint of 




Fig. 703. — Adhesive plaster applied for traction and coun- 
ter-traction with, the short Desault splint. Adhesive on upper 
part of leg is applied to pull upward while that on the lower 
part of leg to pull downward when the splint is in position. 

Fig. 704. — Short Desault splint in position, with padding 
about leg. Tightening the screw at the foot of the splint affords 
traction and counter-traction. 



) 



■^i 



plaster, Du Puy splint, etc., have all been suc- 
cessfully used, and it is largely a matter of 
preference with the surgeon which of these meth- 
ods of fixation is employed. The author has 
used both the pillow splint and the .fracture-box 
with considerable satisfaction. The fracture- 
box is made of four pieces of wood as shown in 
Figs. 698 and 699. The inside of the box is 
well padded with cotton batting to fill in the 
spaces between the leg and the walls of the box. 
The sides of the box should be hinged so they can 
be lowered for inspection of the limb and read- 
justment of the padding. The pillow splint is 
made by placing the leg longitudinally on a pil- 
low, which is then folded up on either side of 
the leg and held in position by encircling straps 
of adhesive, bandages, or ordinarj^ straps with 
buckles, either of canvas or leather. If three 
splints are placed in position before the straps 
are tightened the whole appliance will be ren- 
dered much more rigid. These splints should be of light wood 
three and a half to four inches in width and should be placed 
between the straps and the pillow, one on either side and 



704. 



6^6 



FRACTURES AND DISLOCATIONS 




Fig. 705. — Cabot posterior wire splint. A. shows wire bent to conform to shape 
of leg. B. shoAvs same padded and bandaged. C. shows same after space has been 
filled in by bandaging. D. shows splint applied to leg and bandaged in position. 




Fig. 706. — N. R. Smith's suspension splint. A. shows wire splint bent to conform 
to anterior surface of leg B. C. shows splint applied and leg suspended. 



FRACTURES OF SHAFTS OF THE BONES OF LEG 



647 



the third posteriorh\ The pillow splint and fracture-box are as 
good as any and can be improvised even under unfavorable 
surroundings. The Cabot posterior wire splint and side splints 
are a favorite method with some surgeons. The fragments 




Fig. 707. 



Fig. 707. — Elevated fracture-box. Of advantage in cases in which circulation of leg 
is much injured or in which flexion is required to maintain reduction. It is difficult, 
however, to render this form of box stable in bed. 

Fig. 708. — Cradle used to prevent bed clothes from resting on injured member. 

should be brought into alignment with the least possible manip- 
ulation as the leg is being placed on the temporary splint. 
Oblique and spiral fractures are common in the shaft of the tibia 
and it may be necessary to control the overriding deformity during 





Fig. 709. 



Fig. 710. 



Figs. 709 and 710. — Methods of securing traction on fractures near the ankle by 
means of adhesive straps. 





Fig. 711. 



Fig. 712. 



Fig. 711. — Old shoe with toe cut out and adhesive straps for obtaining extension. 
Fig. 712. — Method of relieving the heel from pressure. 



this time, especially if the pointed end of one of the fragments 
threatens to perforate the skin, as is not infrequently the case. 
Under these circumstances an extension apparatus should be ap- 
plied to the foot. This is often a difficult matter if the materials 



648 FRACTURES AND DISLOCATIONS 

used are the same as those employed in Buck's extension, in frac- 
tures of the hip. Adhesive plaster when applied to the foot and 
ankle is likely to irritate the skin, because of the small area to 
which it can be attached. The author has found the following 
method very satisfactory in instances in which extension was found 
necessary. The patient 's shoe is cut so that the ' ' upper ' ' is divided 




Fig. 



Fig. 713. — Anterior and posterior plaster splints applied to leg and held in posi- 
tion by encircling straps of adhesive plaster. 

Fig. 714. — Plaster stirrup. The two side splints are made of one continuous piece 
of gauze which passes under foot. As a permanent dressing this splint is probably the 
most efficient and satisfactory in fractures of the leg. 

from the sole. Slits are then cut in the sides of the "upper" and 
adhesive straps passed through them to be carried below the foot 
to a spreader, the same as employed in Buck's extension. The 
upper is then placed on the foot, the lacings tightened and a weight 
attached to the cord after it has been passed through a pulley se- 
cured to the foot of the bed. Six, eight or ten pounds will usually 



FRACTURES OF SHAFTS OF THE BONES OF LEG 649 

suffice iu correcting the deformity but the amount of weight em- 
ployed should be governed entirely by the degree of muscular 
spasm to be overcome. Extension can be exerted in this way 
without irritating the foot and ankle during the time it is fixed on 
the temporary splint ; counter-extension is had by raising the lower 
extremity on an incline plane or by raising the foot of the bed. 
Instead of splints, sand bags may be placed on either side of the 
leg and will serve the purpose well in steadying the parts. 

It is often impossible to forecast the degree of traumatic reaction 
which will follow in a given case and it is therefore best to post- 
pone the application of a permanent splint until this reaction has 
passed. The tension produced by the swelling, the internal lacer- 
ation of soft tissues by the fragments at the time of injury, and 
the not infrequent venous thrombosis about the site of the fracture 
are conditions tending to impede circulation and demand dressings 
which do not constrict the leg. The plaster cast has been exten- 
siveh^ used in the early treatment of fractures of the leg and good 
results have attended its use, yet the author feels that it is an 
unsafe appliance and is inferior in every way to the plaster stirrup 
or plaster splints. With either plaster splints or the plaster stirrup 
the dressings may be tightened or loosened as the occasion demands 
and during the entire course of the case a strip of skin, extending 
the length of the leg, is open to inspection. The plaster cast is 
much safer during the later half of the after-treatment and forms 
a good method of fixation for ambulatory treatment. 

Isolated fractures of the tibia are rarely followed by much swell- 
ing, and fracture of the tibia alone is usually productive of a much 
milder traumatic reaction than occurs when both bones of the leg 
are fractured. The surgeon is usually able to estimate, with more 
or less accuracy, the degree of traumatic reaction to follow in a 
given case. Occasionally, however, cases are encountered which 
promise little in the way of swelling when first seen, and yet a few 
days later show the most marked symptoms. If such a case is 
wearing a permanent dressing of the nature of a plaster cast, great 
damage may be done to the leg before either the surgeon or the 
patient realizes the condition. 

Numerous modifications of splints (such as the Desault and plas- 
ter traction splints) have been devised to maintain reduction by 
means of extension and counter-extension until the fragments have 
become firmly enough united to prevent displacement. These ap- 



650 FRACTURES AND DISLOCATIONS 

pliances are well enough as a permanent dressing, in instances in 
which operation is contraindicated because of disease, age or lack 
of surgical facilities, but under ordinary circumstances they are 
to be considered as obsolete and to be discarded in favor of operative 
methods with direct fixation of the fragments. 

The treatment of compound fractures of the bones of the leg is 
essentially operative, at the present time, and with the vastly better 
results obtained in this way, there can be nothing but censure for 
non-operative methods, provided there are no constitutional con- 
traindications and surgical facilities are available. (See ''Opera- 
tive Treatment," below.) A common and serious mistake in the 
treatment of compound fractures in this region is to effect an imme- 
diate reduction as soon as the case is seen, often on the street or in 
the factory. This procedure has probably been responsible for the 
loss of many legs which could otherwise have been saved. The ends 
of the fragments projecting through the skin must be considered in- 
fected and if an immediate reduction is performed the patient will 
be fortunate, to say the least, if the entire tract does not become 
septic, with the usual disastrous train of symptoms following. 
Instead of attempting immediate reduction, the wound and exposed 
bone should be covered with a sterile dressing and the patient re- 
moved to surroundings in which proper surgical procedures can be 
carried out. (See "Treatment of Compound Fractures," page 
789.) 

Operative Treatment. — There are four sets of circumstances 
which commonly call for operative treatment. First, to accom- 
plish and maintain reduction in recent cases in which non-operative 
methods have failed ; second, in the treatment of compound frac- 
tures; third, when non-union is present, and fourth, for the correc- 
tion of old fracture deformities. 

A large proportion of closed fractures of the leg demand operative 
intervention to secure the best results. The best time for operation 
in simple cases is after the traumatic reaction has subsided, which 
will be at the end of a week or ten days. The most aseptic tech- 
nique should be followed and other precautions observed such as 
are mentioned on page 754 under the heading of "Open 
Treatment of Fractures." A longitudinal ijicision should be 
made, preferably to the outer side of the midplane of the leg, so 
that the external surface of the bone will be exposed. It is not 
advisable to make the incision opposite the internal surface of the 



FRACTURES OF SHAFTS OF THE BONES OF LEG 



651 



tibia, since this face of the shaft is subcutaneous. In difficult cases 
two incisions ma}^ be made, one as already described and the other 
opposite the internal border of the bone on the inner aspect of the 
leg. Traction and direct manipulation of the fragments will ac- 
complish reduction and occasionally it may be possible to obtain a 
solid engagement of the serrated surfaces, thus obviating the ne- 
cessity of direct fixation. In most instances, however, in which 
operation is indicated, it will be found necessary to resort to some 
form of internal fixation to prevent recurrence of deformity. A 
very satisfactory method of securing the fragments, and one which 




Fig. 71G. 



Figs. 715 and 716. — Lateral and antero-posterior views of comminuted fracture of 
tibia. Transverse fracture of fibula. 



will serve the purpose in most oblique and spiral fractures, is shown 
in Fig. 717. This consists in passing two wires about the shaft of 
the bone. The distance between them should be at least an inch, 
to secure the proper leverage. In some instances the Lane plate 
can be used to advantage. Transverse fractures can often be en- 
gaged in such a manner that no internal fixation is necessarj^ If 
a plate is used it is preferable to place it on the external surface 
of the shaft so that it will not be subcutaneous. In knotting or 
twisting wire, the twists or knots should be placed on this same 
surface. With the wires or plate in position the strength of the 
fixation should be gently tested to see that the fragments are 
solidly enough held. It should be possible to raise the foot by the 



652 



FRACTURES AND DISLOCATIONS 



heel without disturbing the relative positions of the fragments. 
When the internal fixation has been completed and tested the 
wound should be closed and a small drain of silkworm gut placed 





Fig. 717. 



Fig. 



Fig. 717. — Same case as shown in Figs. 715 and 716. X-ray plate made three 
weeks after operation in which the bones were wired in two places. Aseptic healing 
and ultimately perfect function. 

Fig. 718. — Same leg shown on posterior plaster splint. The anterior splint has been 
removed to dress wounds. (See Fig. 713.) 



in position to allow the escape of blood and serum during the first 
twenty-four or forty-eight hours. A heavy plaster stirrup should 
be applied before the patient comes out of the anesthetic. A quick 
drying plaster should be used so that the stirrup may be well set 



FRACTURES OF SHAFTS OF THE BONES OF LEG 653 

before the patient leaves the operating room. If a sheet, narrowly 
folded lengthwise, is passed once around the thigh just above the 
knee, and the ends secured to the side rails of the bed, it will pre- 
vent the patient moving the lower extremity while coming out of 
the anesthetic, and will be of valuable assistance to the attendant 
during this time. The leg should not be covered with the bed 
clothes during the first twenty-four hours following operation, so 
that the plaster may become thoroughly hardened and dried out. 
Failure to observe this precaution will probably necessitate the 
reapplication of the dressing, to say nothing of the possibility of 
damage to the limb through lack of support. 

In compound cases the patient should be taken to the operating 
room as soon following the accident as possible. An anesthetic 
should be given, the skin surrounding the wound painted Avith 
five percent iodine and the incision enlarged if necessary. The 
wound should be irrigated with a few gallons of sterile salt solu- 
tion. Completely detached fragments of bone should be removed 
and the main fragments brought into as good alignment as possible. 
Devitalized tissue should be trimmed away and oozing controlled 
by hot salt solution. Active bleeding from small arteries should be 
stopped by torsion, if possible, rather than by ligature. Internal 
fixation of the fragments at this time is contraindicated regardless 
of the material used. The freshened surfaces of the wound should 
be approximated and a small drain of silkworm gut left iii position 
to allow the escape of blood and serum. Dressings are then ap- 
plied to the wound, the leg covered with a layer of sheet cotton 
and a plaster stirrup employed as already described. When the 
patient is transferred to the bed the leg should be well elevated 
and an ice cap (one that does not leak) is placed on the anterior 
aspect of the leg in the region of the fracture. An attempt should 
be made during the operation to secure as accurate reduction as 
possible, yet it should be remembered, in these cases, that accurate 
reduction at this time is not the essential. The most important 
factor is to obtain healing of the wound which renders the frac- 
ture compound. If the position of the fragments is bad, a second 
operation may be done at some later date, after the wound has 
healed and the surgeon is free to work in an aseptic field. This 
can usually be done at the end of ten days or two weeks. If sup- 
puration and infection follow, in spite of the measures just ad- 
vised, the fracture must be treated along general surgical lines 



654 FRACTURES AND DISLOCATIONS 

with free drainage, etc. The number of infected cases, however, 
following this line of procednre will be surprisingly small as com- 
pared with the cases in which local applications of bichlorid of 
mercury and other useless antiseptics are the agents depended upon 
to prevent infection. 

Operation may be indicated to correct old fracture deformities 
in which the poor alignment of fragments is accompanied by pro- 
nounced disturbance in function. In a case of this type the sur- 
geon should not be overanxious to operate if the patient is showing 
any improvement whatever. The restoration of function may be 
greatly delayed and still the patient may ultimately obtain a serv- 
iceable member without surgical intervention. AYhen operation is 
necessary the procedure is similar to that already described, with 
the addition of appropriate osteotomy to bring the fragments back 
into proper position. 

When operation is called for because of non-union the first indica- 
tion is to seek the cause of the failure in union. (See Chapter LXI.) 

After-Treatment. — A great deal of care and attention is called for 
in the after-treatment to keep the patient comfortable and to see 
that the dressings are performing their proper function. Repeated 
adjustments will be necessary, especially during the time the leg 
is changing in size, with the onset and passing off of swelling. 
During the first week or ten days the leg should be inspected at 
least daily and readjustments made. Blebs should be opened after 
they have fully formed and the denuded surfaces dusted with 
boric acid or some other efficient dusting powder. These surfaces 
should receive the most careful attention and it must not be for- 
gotten that the member may become infected through such an 
atrium, especially in the presence of low resistance in the surround- 
ing tissues. 

The sooner ambulatory treatment is instituted, following the 
subsidence of traumatic reaction, the better for the patient in gen- 
eral and the fracture in particular. In non-operative cases the 
patient may be gotten up on crutches within five or six days of the 
application of a permanent splint. When open treatment has been 
employed to accomplish reduction, a week should elapse following 
the operation, before the patient is allowed up. In compound 
cases the wound should be well healed and the fragments in good 
position for a week or more before ambulatory treatment is insti- 
tuted. Complicated cases should remain in bed until the outlook 



FRACTURES OF SHAFTS OF THE BONES OF LEG 655 

is favorable and convalescence well established. The patient should 
be allowed np for onl}^ a few minutes during the first day. The 
time should be increased the second day, and so on during the fol- 
lowing week until the limb can be held in the dependent position 
without undue swelling and pain. During this time he will gain 
control of the crutches, and the annoying sensations in the leg, 
attendant upon the erect position, will gradually grow less and 
finally disappear. At the end of nine or ten weeks the foot may 
be placed on the floor as the patient walks with crutches. During 
the following three or four weeks weight bearing should be grad- 
ually resumed. During this time the surgeon should watch the leg 




Fig. 719. — Ambulatory pneumatic splint as used in fractures of the leg. Note the 
extension mechanism at the end of the splint. 

carefully for signs of a weak callus. The slightest bowing or short- 
ening of the leg demands immediate cessation of weight bearing. 
Swelling is often persistent and pronounced and should be treated 
by daily massage and immersion of the leg in hot water once or 
twice a day. An elastic stocking worn during the day will aid 
materially in controlling this swelling. The older the patient the 
longer the time necessary for the formation of firm weight bearing 
callus. In the very aged it may be impossible to obtain union at 
any time. In the exceptional case in which the surgeon may be 
in doubt as to the best time for the resumption of function, an 
X-ray plate will afford the desired information concerning the con- 
dition and progress of callus formation. 



656 



FRACTURES AND DISLOCATIONS 




Fig. 720. — Old fracture of the tibia and fibula with discharging: sinus eight years 
later. The condition has been an intermittent source of trouble during the entire "eight 
years. This is a good example of a type of case requiring operation for the removal 
of necrotic bone. 




Fig. 721.- — Picture taken to show the swelling which so frequenth- persists follow- 
ing fractures of the bones of the leg especially with patients past middle life. Picture 
taken some months following the accident. The ring about the leg corresponds to the 
upper end of the elastic stocking. 



FRACTURES OF SHAFTS OF THE BONES OF LEG 



657 



Prognosis. — The prognosis in fractures of the leg is extremely 
variable and depends largely on the associated injuries to the soft 
tissues and "whether or not a compound fracture becomes infected. 
Persistent swelling is common and may last for years. It is de- 
pendent on the damage done to the circulation at the time of the 
injury and on the development of venous thrombosis following the 
accident. The more severe these conditions, the more pronounced 
and persistent will be the swelling when function is resumed. Pain 
in the leg may persist for months or even years following the acci- 
dent. Considerable disturbance in function usually follows vicious 
union of the fragments and is due to the mechanical strain imposed 





Fig. 722. 



Fig. 723. 



Fig. 724. 



Fig. 725. 



Figs. 722, 723, 724 and 725. — Show the mechanical disturbances which follow union 

with deformity. When the leg diverges from the weight-hearing line the leg will be 

mechanically "off" and as a result there will be more or less permanent disturbance in 
function. 



on both muscle and bone by this faulty position. The more per- 
fect the apposition of the fragments and the less the damage to soft 
tissues at the time of the accident, the less pronounced will these 
annoying sequelae be. The percentage of cases in which perfect 
and prompt restoration of function occurs, has greatly increased 
since the advent of open treatment for the accurate correction of 
deformity. 

In compound infected cases, sinuses may persist until the 
necrotic bone from which they lead is removed by operation. 
Refracture of the bones of the leg may occur if sufficient strain is 
sustained before the callus becomes thoroughly hardened. Refrac- 
ture is through the callus and not the fragments. About one-half 



658 FRACTURES AND DISLOCATIONS 

to two-thirds the time required for union in the original break is 
necessary for union in a fractured callus. Embolism from a de- 
tached portion of thrombus or a fat embolus may produce immedi- 
ate death. Infection in compound cases may result in the loss of 
the leg, or if severe, even death. Destruction of the circulation in 
severe crushing injuries calls for immediate amputation. 



CHAPTER XL VI. 

POTT'S FRACTURE. 

Pott 's fracture is both a fracture and a dislocation, and although 
it is usually included under the heading of fractures, yet it is 
probably more in accordance with the pathology of the condition 
to consider it as a dislocation complicated by fracture. 

Aside from fracture of the fibula, Pott's fracture is the most 
common injury of importance occurring in this region, and be- 
cause of this frequency and the poor results so often seen following 
its improper treatment, it will be taken up under a special heading. 

Surgical Anatomy. — There are three bones entering into the 
formation of the ankle joint: the tibia, fibula and astragalus, and 
the disposition of these three bones is of great importance surgically. 
The trochlear surface of the astragalus fits the articular surface 
of the lower end of the tibia and is held in place laterally by the 
malleoli. Lateral motion between the astragalus and tibia is pre- 
vented by the tight, firm, mortise-like formation of the tibia and 
fibula. The two latter bones are held together by the lower tibio- 
fibular ligaments, the most important of which is the inferior in- 
terosseus, which passes between the contiguous rough surfaces of 
the tibia and fibula. These ligaments are so strong that separation 
of the two bones rarely takes place without fracture of either the 
tibia or fibula. The lateral ligaments are also of great strength 
and are more likely to tear away their attachments than to suffer 
rupture. They bind the astragalus and calcaneum to the lower 
end of the tibia but have little to do with the limitation of normal 
flexion and extension. The anterior and posterior ligaments are 
thin, loose and lax, and are not brought to a tension until the ankle 
either comes to extreme flexion or extension. When the foot is 
depressed to its limit of motion the anterior ligament becomes taut 
and in like manner the posterior ligament is brought to a tension 
when the ankle is dorsally flexed. Distention of the joint is first 
noted in the bend of the ankle where the thin anterior ligament is 
pushed forward by the fluids within the articular cavity. The 

659 



660 FRACTURES AND DISLOCATIONS 

outer malleolus is longer and extends to a lower level than the 
inner malleolus. If the normal alignment of the bones of the leg 
with the astragalus and calcaneum is observed it will be noted that 
the heel rests on the ground outside of the median plane of the 
leg (see Figs. 726 and 727). It will be readily seen, therefore, 
that violence applied in a longitudinal direction, such as is sus- 
tained in a fall from a height in. which the patient lands squarely 
on the foot, will tend to displace the foot outward as well as up- 




Fig. 726 



Fi?. 72G. — Shows the mortise formed bv the tibia and fibula into which the astragalus 
fits. E.M., External Malleolus; I.M., Internal Malleolus; A., Astragalus; E.A., Head 
of Astragalus. 

Fig. 727. — Same view of ankle with calcaneum in position. A line drawn through 
the long axis of the tibia falls to the inner side of the heel, hence the frequency of talipes 
valgus in injuries of this region. E.M., External malleolus; I.M., Internal malleohis ; 
A., Astragalus; H.A., Head of Astragalus; C, Calcaneum. 

ward. It is apparent that this displacement cannot take place 
without producing fracture and ligamentous rupture. The points 
of least resistance will be found in the fibula just above the lower 
tibio-fibular articulation and in the internal lateral ligament of the 
ankle joint or its attachment to the inner malleolus. AVhen these 
conditions prevail we have the typical Pott's fracture as shown in 
Figs. 729 to 731. Compare the positions of the bones as indicated 
in Fig. 729 with the clinical appearance of the deformity as shown 



POTT S FRACTURE 



661 



in Figs. 740 to 745. Outward rotation of the foot, on a more or 
less vertical axis passing through the astragalus, probably plays a 
part in the production of many Pott's fractures, by prying the 
malleoli apart. When this type of strain enters into the causative 
trauma the fibular fracture is usually spiral instead of transverse. 
In addition to the lesions just mentioned we may find either the 




Fig. 728. — Normal ankle showing the epiphyses at thirteen years of age. 



anterior or posterior margins of the lower tibial surface broken off 
and displaced. 

The constant element in Pott's fracture' consists of a fracture 
of the fibula within two or three inches of the lower tibio-fibular 
articulation. The variable element is at the inner malleolus, wiiere 
either the deltoid ligament is ruptured or the tip of the inner 
malleolus torn away. Numerous descriptions have been given of 
the exact manner in which a Pott's fracture is produced and the 
order in which the different lesions take place ; as a matter of fact 



662 



FRACTURES AND DISLOCATIONS 




Fig. 729. — Pott's fracture with the usual outward displacement. Note the space 
between the inner malleolus and the astragalus. 

Fig. 730. — Variant of Pott's fracture. Incomplete fracture of fibula with avulsion 
of portion of tibia, corresponding to insertion of lower tibio-fibular ligament. 




Fig. 731. 



Fig. 



Fig. 731. — Pott's fracture. Comminution of fibula and fracture of inner malleolus. 

Fig. 732. — Pott's fracture. Comminution of fibula and fracture of inner malleolus. 

Fig. 733. — Variant of Pott's fracture. Fracture of inner malleolus and diastasis of 
lower tibio-fibular joint. The s-eparation previously existing between the lower ends of 
the tibia and fibula has been corrected at the time of reduction, and hence the diastasis 
is not apparent in the Rontgenogram. 



POTT S FRACTURE 



663 



it is difficult to state whether the internal lateral ligament ruptures 
before the fibula breaks, or whether the bone breaks before the 




Fig. 735. 



Fig. 736. 



Fig. 734. — Pott's fracture. Fracture of inner malleolus. 
Fig. 735. — Pott's fracture. Fracture of inner malleolus. 
Fig. 736. — Pott's fracture with fracture of inner malleolus. 




Fig. 739. 



Fig. 737. — Pott's fracture. Comminution of fibula and fracture of inner malleolus. 

Fig. 738. — Old Pott's fracture. Incomplete reduction. 

Fig. 739. — Lateral view of old Pott's fracture. Note old fracture in fibula. 



ligament ruptures. Probably the latter mechanism obtains in most 
cases. Instances of Pott's fracture by inversion of the foot have 



664 



FRACTURES AND DISLOCATIONS 



been reported in whicli the shaft of the fibula was fractured by the 
inward pull on the external malleolus, and the inner malleolus 
fractured by direct pressure of the astragalus. The production of 
Pott's fracture by this mechanism is rare. Separation of the lower 
ends of the tibia and fibula have occurred as a result of rupture of 
the tibio-fibular ligaments or a wrenching off of their bony attach- 
ments, this condition however cannot be properly called a Pott's 
fracture. It will be considered under dislocations of the ankle. 
"When the lateral displacement of the foot is great the inner 
malleolus (or what is left of it after the tip has been avulsed) 
may be forced through the skin, thus rendering the condition com- 
pound and exposing the ankle-joint to infection. _ 




Fig. 740. — Pott's fracture of the left ankle a tew ini!uit<-s tollowing injury. De- 
formity moderate though characteristic. Note the outward dibplacemeut of the foot and 
the prominence of the inner malleolus. The difference in the contour of the two ankles 
may be readily recognized even though the shoe on the right foot has not been removed. 
Inner arrow points to ruptured deltoid ligament. Outer arrow indicates level of fibular 
fracture. 



An '^inverted" or "reverse" Pott's fracture is an inward frac- 
ture-dislocation of the ankle and will be discussed under the head- 
ing of "Dislocations of the Ankle," on page 684. The treatment 
of this condition is essentially different from that of Pott 's fracture 
and the two lesions should not be confounded. 

Symptoms. — Immediate and complete loss of function, pain and 
characteristic deformity, following an injury to the ankle, are the 
typical symptoms occurring in Pott's fracture. The foot is in a 
position of more or less pronounced eversion and the inner malleolus 
is more prominent than normal. It is often impossible to elicit 



POTT S FRACTURE 



665 



crepitus but abnormal mobility will be recognized when the lateral 
stability of the ankle is tested. If the foot is viewed laterally an 
abnormal prominence of the heel will usually be noted and the 
dorsum of the foot will be found somewhat shortened. Measure- 




rig. 741. 




Fig. 742. 



Figs. 741 and 742. — Simple Pott's fracture the result of a fall on the foot. Note 
prominence in region of internal malleolus and eversion of ankle, which is present in 
both upright and recumbent positions. Note also depression about one inch above 
external malleohis which corresponds to fracture in fibula. Photographed about twenty 
minutes following accident. 



ments should be made from the anterior edge of the lower tibial 
articular surface to the base of the phalanx of the great toe, and 
compared with the opposite foot. Swelling follows the injury 
rapidly and tends to mask the deformity. The ankle-joint becomes 



666 



FRACTURES AND DISLOCATIONS 



distended with blood and synovial fluid. The entire ankle is ten- 
der and painful, especially in the region of the fibular fracture and 
below the internal malleolus. Ecchymosis usually develops within 
the first twelve or twenty-four hours. If the fracture is allowed 
to go untreated or if the condition is not properly diagnosed and 
the deformity fully corrected, recovery takes place with the foot 
in aversion and backward displacement. This means great and 
permanent loss of function. There are two elements in the de- 
formity; firstly, the eversion of the foot and secondly, the back- 




Fig. 



Anotht-r view of the case shown in Figs. 741 and 



ward displacement, both of which tend to recur as soon as the parts 
are released. 

Diagnosis. — There should be little difficulty in recognizing the 
condition, especially if seen before the swelling has become pro- 
nounced. The deformity is. characteristic, as shown in the accom- 
panying illustrations. The eversion, backward displacement, ab- 
normal mobility, pain, loss of function and sometimes crepitus 
should enable one to recognize the condition as soon as seen. An 
X-ray plate, however, is of great value in determining the details 
of the injury and the presence of unusual complicating fractures 
when they occur. It is of especial importance in ascertaining the 



POTT S FRACTURE 



667 



position of the fragments after reduction has been attempted. As 
previously stated the traumatic inflammatory reaction tends to 
mask the deformity, yet the disturbed alignment is generally ap- 
parent even Avhen the swelling is extreme. In the usual supra- 
malleolar fracture the break in the tibia may be recognized above 
the ankle-joint, and the malleoli are not spread as in Pott's frac- 
ture. In longitudinal splitting of the lower end of the tibia the 



Fig. 744. 




Fig. 745. 

Figs. 744 and 745. — Recent Pott's fracture seen from behind. Note the outward 
displacement of the foot and the prominence of the inner malleolus. Deformity cor- 
rected by drawing the foot inward and forward. 

diagnosis is sometimes difficult without the aid of the X-ray al- 
though it will often be possible to elicit an abnormal mobility not 
seen in Pott's fracture. 

Splitting off of a small portion of bone, including the tibial at- 
tachment of the lower tibio-fibular ligaments and a part of the 
lower tibial articular surface, may permit of independent motion 
between the malleoli, but is often particularly difficult to recognize 
unless a Rontgenogram is made. 



668 FRACTURES AND DISLOCATIONS 

There is no distinction to be made between outward dislocation 
of the foot and Pott's fracture; they are practically the same con- 
dition. In inward dislocation of the ankle the foot is displaced 
inward and the accompanying fracture in the fibula is at a lower 
level, while the fracture in the tibia is at a higher level, than is 
seen in Pott's fracture. In forward dislocations the foot is dis- 
placed forward and in backward luxations, backward instead of 
the typical outward displacement accompanying Pott's fracture. 

In some instances the characteristic deformity of Pott's may be 
absent because of the ankle having been pulled back into position 
before the surgeon sees the case. The lateral stability of the ankle, 
however, is destroyed and when an attempt is made to displace the 
foot outward this fact is recognized and the typical deformity is 
produced. 

Treatment. — The indications in the treatment of Pott's fracture 
are to correct the eversion and backward displacement of the foot, 
and to see to it that these two deformities are completely reduced 
and maintained in position until the callus formation and liga- 
mentous repair are sufficiently strong to prevent recurrence. 

As an emergency method Dupuytren's splint is particularly sat- 
isfactory but should be replaced b}^ Stimson's plaster splints within 
a week. 

The deformity should be corrected as soon as possible and meas- 
ures instituted to control the inflammatory reaction which is to 
follow. 

The recumbent position, elevation of the injured foot and the 
intermittent use of the ice cap over the seat of fracture will relieve 
the pain and control the swelling. If the trauma producing the 
injury was severe and the swelling is great it may be best to treat 
the fracture on a pillow splint for the first few days. 

Dupuytren's splint.— A board as broad as the calf of the leg, and 
from one-fourth to five-eighths inches in thickness extends from 
below the knee to a point a few inches below the foot. It is heavily 
padded above the fracture with a folded sheet of sufficient thick- 
ness to allow complete inversion of the foot without the latter 
touching the splint (see Fig. 746). The lower end is notched so 
that turns of bandage may be secured to the end of the splint. The 
splint is fastened to the leg with bandages or strips of adhesive, the 
foot forced into inversion and held in position as shown in the ac- 
companying illustrations. In this way the outward displacement 



POTT S FRACTURE 



669 



is corrected and maintained in reduction. The backward deformity 
is more difficult to correct when this splint is employed. The foot 
should be pulled forward as the bandages are being applied, but 
the risk of subsequent backward slumping of the foot is consider- 
able and requires constant watching. This method is of value as 
an emergency dressing, especially since the necessary materials are 
readily obtainable under almost all circumstances. After the splint 
is applied the patient should remain in the recumbent position with 
the injured member elevated on a pillow and the ice cap applied. 
The change in the size of the parts as a result of swelling, renders 
it inadvisable to employ a plaster dressing early in the treatment 
of Pott's fracture. 



aaI^ 




Fig. 746. — Shows the making and use of Dupuytren's splint for the treatment^ of 
Pott's fracture. This splint is most satisfactory as an emergency measure and during 
the acute traumatic reaction. A. shows board with notched lower end. B. shows pad- 
ding applied, which is thickest at ankle. C. shows same bandaged in position. D. shows 
lower extremity in proper relation with splint. E. shows foot forced into adduction. F. 
shows bandages applied. Some of the turns passing over the foot are caught in the 
notched end of the splint, thus rendering adduction more firm. If the traumatic re- 
action is extreme it may be best to dispense with all forms of bandaging and treat the 
lee: in a fracture-box or on a pillow splint for the first few days. (See Figs. 698 to 
702 and 707.) 



The Cahot posterior wire splint with side splints is a satisfactory 
dressing both in the early and late stages of the treatment of this 
fracture and has been used with considerable success by some sur- 
geons. In the early stages, however, it has no advantage over 
Dupuytren's splint and interferes somewhat with the application 
of the ice cap. In the later stages it is not as perfect a method as 
is that of Stimson, in which the lateral and posterior plaster splints 
are. used. 

Stimson' s plaster splints constitute the most satisfactory perma- 
nent dressing known for the treatment of Pott's fracture. The pos- 
terior splint, which is applied first, extends down the back of the 



670 FRACTURES AND DISLOCATIONS 

leg and heel and under the sole of the foot to the toes. The lateral 
splint should extend from about the upper end of the fibula, down 
the external aspect of the leg, under the sole of the foot, over the 
dorsum to the external malleolus. These splints are best made of 
gauze folded and cut to the proper length and about four inches 
in width. If a twenty-five yard bolt of gauze, such as is found in 




Fig. 74 7. Fig. 748. 



Figs. 747 and 748. — Stimson's plaster splints applied to a Pott's fracture and held 
in position by strips of adhesive plaster. Note how the foot has been inverted and 
brought forward until the relations are normal. Results in this case were complete 
restoration of function and absence of deformity. 

the usual hospital supplies is available, the desired amount may 
be cut from it without waste and each splint is thus made of one 
piece. Each splint should be from twelve to eighteen ply, according 
to the size and musculature of the patient. These strips of gauze 
are soaked in plaster cream, wrung out and placed in proper posi- 
tion on the leg. The posterior splint is applied first and then the 



671 

lateral splint. The lower end of the lateral splint, encircling the 
foot, should be overlapped by the straight portion on the outer 
aspect of the ankle (see Fig. 748). The splints are placed in posi- 
tion and brought quickly into snug position by a roller bandage. 
The surgeon then takes his place at the foot of the table and forces 
the foot forward and into adduction while the plaster is still wet. 
This attitude is maintained until the plaster has set sufficiently to 
maintain the proper reduction. During this time the weight of the 
foot and lower extremity rests on the heel in the surgeon's hand 
thus forcing the foot forward and correcting the usual backward 
displacement. Some cases may require more force than is exerted 
by the weight of the limb in overcoming this posterior deformity. 
A quick-setting plaster should be used, otherwise the holding of 
the foot in inversion will be unduly tedious. If the condition is 
compound the lateral splint may be applied to the inner side of 
the leg with equal efficiency. If gauze is not at hand the splints 
may be made of four-inch plaster bandages soaked in water and 
run back and forth on a table until the proper thickness has been 
attained. 

It should be remembered in reducing an ordinary Pott's frac- 
ture that the deformity cannot be over-corrected. 

An anesthetic is always advisable in reducing the deformity and 
in the application of a permanent dressing, unless some constitu- 
tional condition exists to act as a contraindication. 

Following reduction a Eontgenogram should be taken to verify 
the position of the fragments. 

The usual Pott's fracture can be reduced without difficulty as 
just described ; occasionally complications exist such as the interpo- 
sition of a fragment between the astragalus and the inner malleolus, 
which render reduction without operation impossible. 

Operative Treatment. — The open method is indicated when good 
reduction cannot be accomplished by non-operative methods or 
when the fracture is compound from the first. If reduction has 
been attempted and failed, the X-ray will usually reveal the cause 
of the failure, if it has not already been learned through palpa- 
tion and inspection. If, after complete inversion has been accom- 
plished, the upper end of the fibular fragment remains displaced 
inward against the tibia and there is undue space between the ex- 
ternal malleolus and astragalus, it will be advisable to make an 
incision over the fibular fracture, engage the fractured surfaces 



672 FRACTURES AXD DISLOCATIONS 

and secure tlie fibula in proper alignment. If internal fixation is 
found necessary to maintain reduction a Lane plate or wire may 
be used. If this inward displacement of the upper end of the 
lower fibular fragment is allowed to persist it means a widening of 
the mortise by outward displacement of the external malleolus, 
and a weak ankle will result. The interposition of a fragment be- 
tween the inner malleolus and astragalus calls for removal of the 
obstructing material. This is best accomplished through a longi- 
tudinal incision below the inner malleolus. AYith the parts exposed 
the inner lateral ligament should be sutured before the incision is 
closed. 

Operation is sometimes called for because of loss of function and 
painful joint following an imperfectly reduced Pott's fracture. 
^hen a patient presents himself for treatment under these circum- 
stances the case should be carefully studied by the usual examina- 
tion and the X-ray before an opinion or advice is given. The 
exact cause of the disturbed function should be accurately ascer- 
tained, and then, if surgical intervention offers relief, the parts 
should be opened. The usual causes of loss of function are trau- 
matic flat-foot and backward displacement of the foot. Both of 
these conditions can. as a rule, be corrected by osteotomies or read- 
justment of the articular surfaces. The joint is best approached 
through two longitudinal incisions over the malleoli. Through the 
inner incision obstructing materials such as bone or periosteum may 
be removed from l^etween the astragalus and inner malleolus. 
Through the outer incision the position of the external malleolus 
may be corrected, if in deformity, and an osteotomy of the fibula 
aboA'e the tibio-fibular ligaments may be performed if found neces- 
sary to bring the malleolus back into position. Obstructing fibrous 
tissue should be removed if present. The common method of cor- 
recting an old Pott's fracture deformity is by a double osteotomy 
of the tibia and fibula above the ankle. By this means the foot and 
ankle are brought back into proper alignment with the leg and 
both the outward and the backward displacements are corrected. 

If the fracture is compound the lacerated edges should be ex- 
cised, the wound and joint cavity thoroughly washed with a few 
gallons of physiological sterile salt solution and the parts closed. 
If infection follows in spite of this treatment the joint should be 
injected with ]\Iurphy's glycerine-formaline solution and the con- 
dition treated according to the principles laid down under the head- 



POTT 'S FRACTURE 673 

ing of "Compound Dislocations" on page 789. If the case is seen 
early and the treatment just mentioned followed it will usually be 
possible to obtain aseptic healing even though the fracture is badly 
compounded. Following operation splints should be applied as 
already described. 

After-Treatment. — In the usual case of simple Pott's fracture the 
ankle should be maintained in adduction for a period of six weeks. 
No weight should be borne on the injured foot within two months 
of the time of the fracture. ]\Iassage of the leg, especially the calf 
muscles, is of advantage after the first week but it is best not to 
remove the splints early in the after-treatment lest recurrence of 
deformity take place. 

There is a marked tendency to the development of flat-foot fol- 
lowing Pott's fracture and it is due to incomplete reduction of the 
displacement or the too early use of the foot in bearing the weight 
of the body. Two months is a longer period than is usually ad- 
vised before weight is borne on the foot, yet the author has found 
that if this length of time is allowed before the parts are subjected 
to strain, the patient does not develop flat-foot. The use of arch 
supports in the late after-treatment is an admission in itself that 
weight is being borne on the foot too soon. Passive motion of the 
foot, however, should be begun early but must be guarded lest out- 
ward strain be placed on the ankle. The foot should be carried 
through dorsal and plantar flexion but eversion must not be made. 
By means of massage, hot applications and passive motion the func- 
tion of the joint should be well restored before the patient is al- 
lowed to bear his weight on the member in walking. Passive mo- 
tion should be applied to the joints of the tarsus as well as to the 
ankle-joint proper, so that the full flexibility and usefulness of the 
foot may be restored. 

Prognosis. — If proper reduction is accomplished and sufficient 
time is allowed for the solid repair of bone and ligament, in a 
healthy adult, the joint should be practically as useful and strong 
as before the injury. The older the patient, the longer the conva- 
lescence and the more incomplete the restoration of function. A 
certain amount of restriction of motion is common following this 
fracture and seems to be unavoidable. Cases in which accurate 
reduction has been accomplished and early passive motion insti- 
tuted, show the greatest freedom of motion when recovery is com- 
plete. Extreme dorsal flexion is the motion most commonly re- 



674 FRACTURES AND DISLOCATIONS 

stricted and the one least essential in the use of the foot. Traumatic 
flat-foot following Pott's fracture is a serious, crippling deformity 
and shows a tendency to grow worse when once established. Con- 
siderable relief may be had by the use of orthopedic appliances 
such as used in the treatment of flat-foot from other causes. Steel 
or felt arches to support the inner side of the foot and a building 
up of the inner side of the sole, may enable the patient to get about 
with more or less ease if the deformity is not too great. 

Considerable improvement will usually take place during the 
first two or three months of active use and weight bearing. 

Loss of lateral motion in the foot may be productive of lame- 
ness and constitute a serious disability. Lateral motion is not one 
of the normal actions of the ankle-joint but is accomplished by the 
articulations in the tarsus. It is evident therefore that this condi- 
tion is not the result of the injurj^ sustained by the tibio-fibular 
articulation but follows prolonged immobilization of the foot with- 
out the necessary early passive motion to the tarsus. 



CHAPTER XL VII. 

FRACTURES OF THE LOWER ENDS OF THE TIBIA 
AND FIBULA. 

Surgical Anatomy. — The surgical anatomy of the lower ends of 
the tibia and fibula is similar to that already given under the head- 
ing of "Pott's fracture" on page 659. 

Symptoms. — "When both bones are fractured above the ankle, pain, 
loss of function, crepitus, abnormal mobility and swelling are 
usually present and well marked. The traumatic reaction is often 
less pronounced than that accompanying the usual fracture of the 




Fig. 



Fig. 
Fig. 



749.- 
750.- 



-Splittiug of lower end. of tibia. 
-Splitting of lower end of tibia. 



shaft and the mobility is, as a rule, not so completely flail-like. 
The line of fracture in the lower end of the tibia is quite variable 
and accordingly the deformity is not characteristic. The frac- 
ture may be transverse, spiral, comminuted or longitudinal. Longi- 

675 



676 



FRACTURES AND DISLOCATIONS 




Fig. 751. 



Fig. 752. 



Fig. 753. 



Fig. 751. — Fracture of tip of internal malleolus. 

Fig, 752. — Fracture of internal malleolus at higher level. 

Fig. 753. — Fracture of internal malleolus at still higgler level. 




Fig. 754. — Epiphyseal separation of lower end of tibia complicated by fracture of 
tibial diaphysis. Also fracture of fibula. The result of violence similar to that pro- 
ducing Pott's fracture. 



FRACTURES OF LOWER ENDS OF TIBIA AND FIBULA 



677 



tndinal splitting* of the lower end of tlie tibia entering the joint 
cavity is not at all uncommon and is usually accompanied by trans- 
verse thickening of the ankle. The line of fracture may extend 
from the inner surface of the bone into the joint cavity so that 
the inner malleolus is displaced inward or it may extend from the 
outer surface of the bone into the articulation and allow the frag- 




Fig. 755. 




Figs. 755 and 756. — Fracture of both bones of the leg just above the ankk 
indicate the levels of the two fractures. 



ment and lower end of the fibula to be displaced outward. Diastasis 
of the lower tibio-fibular articulation with separation of the lower 
ends of the bones of the leg is occasionally seen and has been classi- 
fied as a complication of upward dislocation of the ankle when the 
astragalus is displaced upward between the ends of the bones. 
Supra-malleolar fracture of the tibia is usually accompanied by 
fracture of the lower end of ' the fibula. Fracture of the inner 



678 



FRACTURES AND DISLOCATIONS 



malleolus usually occurs as a part of Pott's fracture, but even as 
an isolated injury it is not uncommon. Various types of fracture 
of the lower ends of the tibia and fibula occur as complications of 
dislocations of the ankle and of Pott's fracture, but will not be 
considered under this heading. It is not at all uncommon to see 
one of the tibial fragments projecting through the skin. The de- 





Fig. 757. 




Fig. 758. 

Figs. 757 and 758. — Supramalleolar fracture of both bones -with inward displace- 
ment of the foot. Compare the two ankles. Arrows indicate the levels of the two frac- 
tures. 



formity may be pronounced and in cases resulting from direct vio- 
lence the fragments may remain in the position in which they were 
driven at the time of the accident. Fracture of the lower end of 
the fibula is often attended by remarkably slight loss of function 
especially if the line of fracture is into the lower tibio-fibular ar- 
ticulation. The patient may be able to walk with such a fracture 
although use of the member entails pain. 



FRACTURES OF LOWER ENDS OF TIBIA AND FIBULA 



679 



Diagnosis. — There should, as a rule, be little difficulty in recog- 
nizing fractures in this region but the details of the break are 
often difficult or impossible to recognize without the aid of the 




Figs. 759 and 760. — Fracture of both bones of the leg just above the ankle with 
pronounced inward displacement of the foot. The photographs were taken about twenty 
minutes following injury and show an unvisual displacement. /. indicates the upper 
end of the lower fragment of the fibula. //. indicates the displaced external malleolus. 
III. indicates the internal malleolus. Injury the result of direct violence. 

X-ray. Fracture of the fibula may be mistaken for a sprain unless 
the examination is carefully made. When the fracture is supra- 
malleolar the two malleoli will remain in proper relation to each 
other but will move with the foot and not the leg. When the frac- 



680 



FRACTURES AND DISLOCATIONS 



ture enters the joint cavity it will usually be possible to elicit ab- 
normal mobility of one of the malleoli (the one detached). The 
symptoms in separation of the lower epiphyses are practically the 
same as in fractures of this region except for the crepitus which is 




Fig. 761. 




Fig. 762. 

Figs. 761 and 762. — Splitting of the lower end of the tibia with broadening of. the 
ankle. Both malleoli prominent. Type of case requiring operation to secure the best 
results. 



cartilaginous and not bony. If the fracture in the fibula is above 
the lower tibio-fibular ligaments pressure in the middle of the shaft 
will produce pain at the seat of the fracture. If the fracture is 
through the ligaments or below them direct pressure at the site 



FRACTURES OF LOWER ENDS OF TIBIA AND FIBULA 



681 



of the lesion will be necessary to produce pain. AVlien the fibula 
alone is fractured there is usuall}^ little loss of strength in the 
ankle. 

Treatment. — In fracture of both bones above the ankle or in 
epiphyseal separations the indications in treatment are similar to 
those cases just described in which the fracture is at the usual site 
(the junction of the middle and lower thirds of the shafts). The 
necessity for temporary treatment is not as great in this region 
since the traumatic reaction is seldom as severe as in fracture of 
the shafts. It is best, however, to place the leg in a fracture-box 
or pillow splint for the first few days, until the amount of swelling 
to follow can be determined. During this time the ice cap locally 
and intermittently applied is of great value. A plaster stirrup as 




Fig. 763. — Old case of fracture of both bones of the leg above the malleoli. Patient 
presents himself for treatment because of inability to use limb. Pen outline on skin 
indicates palpation of fibula. This case is a good example of delayed restoration of 
function due to incomplete reduction of fragments. 



already described in "Fractures of the Shaft" will in most cases 
be found thoroughly efficient in maintaining reduction. A quick 
drying plaster should be used and the surgeon should hold the 
ankle in reduction, while the splint is setting. The best position 
for the ankle, in a given case, is the one in which the tendency to 
recurrence of deformity is least. It is preferable to fix the foot 
in a position of slight plantar flexion rather than at a right angle. 
The proper position for the foot, aside from the prevention of 
deformity, is one in which the flexor and extensor muscles are at 
an equal tension and balance each other. In instances in which 
the lower end of the tibia is split longitudinally it will often be 



682 FRACTURES AND DISLOCATIONS 

necessary to force the fragments together, by lateral pressure, while 
the plaster is drying, in order that union maj^ not take place with 
transverse thickening of the ankle and widening of the mortise. 
If the posterior portion of the articular surface of the tibia is 
broken off the foot should be more or less dorsally flexed to favor 
reduction and prevent recurrence. When a fragment is broken 
off of the articular surface anteriorly the foot should be immobilized 
in the opposite position for the same reasons. The foot should be 
covered with a layer or two of sheet cotton before the stirrup is 
applied. The bony prominences about the ankle are subcutaneous 
and if the splint is not properly padded undue pressure may pro- 
duce sloughing of the skin. Fracture of the fibula alone does not 
require as solid immobilization as is the case in isolated fracture 
of the lower end of the tibia or when both bones are broken. 

When an outward displacement of the external malleolus exists 
as a result of fracture of the fibula, whether the break is above, 
below or through the lower tibio-fibular ligaments, the deformity 
should be corrected and held in position by the dressing. Strong 
adduction of the ankle, as in the treatment of Pott's fracture, will 
usually correct this displacement if the internal malleolus is intact. 

Operative Treatment.^ — Open treatment is not as frequently 
indicated in fractures of the lower ends of the tibia as it is when 
the shafts of these bones are broken. It is most commonly called 
for when there is a longitudinal splitting of the lower end of the 
tibia in which difficulty is experienced in approximating the frag- 
ments. Even a slight spreading of the malleoli means a widening 
of the mortise in which the trochlear surface of the astragalus 
rests and this condition, if not corrected, is followed by a pro- 
tracted recovery if not permanent disability. If two longitudinal 
incisions are made, one on the inner and the other on the outer 
aspect of the lower part of the leg, the fragments can be replaced 
by direct manipulation and transverse holes drilled through the 
approximated fragments at the most advantageous points. Heavy 
wire is then threaded through these holes and the ends securely 
twisted to maintain propel* reduction. In some instances passing 
wire around the fragments may be all that is required but this 
point can seldom be determined until the fragments are exposed. 
In supra-malleolar fractures open incision may be necessary to 
effect reduction but it is seldom necessary to employ internal 
fixation. 



FRACTURES OF LOWER ENDS OF TIBIA AND FIBULA 683 

After- Treatment. — If the traumatic reaction is great the leg 
should be treated ou a pillow splint or in the fracture-box during 
the first few days. The swelling is usually less than that seen when 
the fracture is higher, and it will seldom be necessary to wait more 
than four or five days before placing the leg in a permanent splint. 
As previously stated, the plaster stirrup is the most efficient form 
of permanent dressing in which to treat fractures in this region. 
Union may be expected in the healthy adult in six weeks but the 
callus is not sufficiently strong at this time to permit of weight 
bearing. iMassage and gentle passive motion should be instituted 
at the end of the second week. During the eighth and ninth weeks 
weight bearing should be gradually increased until the patient is 
able to walk at the end of two and a half months. The time should 
be prolonged in cases in which the fracture involves the articular 
surfaces and when passive motion is employed due regard should 
be had for the tendency to displacement, if such exists. It is best 
for the patient to walk with a cane for some time following the 
removal of all dressings. Persistent swelling of the ankle should 
be met with massage and hot applications and, if pronounced, great 
relief may be had by the use of an elastic stocking during the 
day. Isolated fracture of the fibula without displacement may, 
as a rule, begin weight bearing at the end of three or four weeks. 

Prognosis. — The more accurate the reduction the more complete 
and prompt is recovery. Some limitation of motion in the ankle, 
especially dorsal flexion, is common, following fractures in this 
region, particularly so when the line of fracture involves the ar- 
ticular surface. Fractures of the fibula alone are usually followed 
by complete restoration of function. The prognosis in other re- 
spects is similar to that already given in "Fractures of the Shafts 
of the Bones of the Leg," page 657. 



CHAPTER XL VIII. 

DISLOCATIONS OF THE ANKLE. 

Surg-ical Anatomy. — The bones entering into the formation of 
the ankle-joint and the ligaments holding these bones in apposition, 
have alread}" been mentioned in the surgical anatomy- of "Pott's 
fracture," on page 659. The manner in whiclr the malleoli are 
placed on either side of the body of the astragalus explains the 
frequency with which fracture complicates dislocations of this ar- 
ticulation. Nearly all the luxations of the ankle are accompanied 
by fracture of either the tibia, fibula or astragalus. One or both 
malleoli may be broken off and displaced with the foot. 

The bones of the ankle are not deeply situated and it is not 
uncommon to see compound luxations of the ankle. When severe 
and direct violence is applied to the ankle, the foot may be torn 
away from the tibia and tibula and displaced in any direction. 
The gi^eater the violence producing the injury the greater the 
probability of the condition being compound and complicated by 
fracture of the malleoli or astragalus. In severe cases the bones 
of the foot may be entirely torn from the lower end of the leg 
with only the soft tissues connecting the two, and a large rent in 
the skin. In such instances the character of the deformity is not 
typical of any of the forms of ankle luxation to be described. 

The typical luxations of the ankle in their order of frecpienc}- 
are : outward, inward, backward, forward, and upward. It should 
be remembered, however, that a given luxation may present a dis- 
placement resembling two forms of dislocation. Thus the foot may 
be displaced forward and inward so that the deformity shows some 
of the characteristics of l30th the forward and inward types of 
dislocation. In many of these luxations (especially the lateral 
types) there may be a rotary element present in which the foot is 
turned either inward or outward on a more or less vertical axis. 
This form of displacement has been described as a separate form 
of luxation, and may occur as such, but is almost always secondary 
to one of the other dislocations just mentioned. 

684 



DISLOCATIONS OF THE ANKLE 



685 




Fig. 764. — YieM' of ligaments of foot from fibular 
A., Astragalus: N., Navicular; C.M., Middle cuneiform 
Calcaneum ; Cub., Cuboid. 



side. E.M., External malleolus; 
C.E., External cuneiform; Gal., 




Fig. 765. — View of ligaments of foot from tibial side. Ciin.I., Internal Cuneiform: 
N., Navicular; A., Astragalus; T., Tibia; Cal., Calcaneum; T.I'., Tendon of tibialis 
posticus; (?., Groove for the passage of the tendon of the tibialis posticus. 



686 FRACTURES AND DISLOCATIONS 

In outivard luxations the lesions are somewhat variable. The 
less severe forms of this dislocation are the same as Pott's fracture, 
which has already been described. When the force w^hich pro- 
duces Pott's fracture continues to act, the lower tibio-fibular liga- 
ments are either ruptured, or tear away their tibial attachment, 
including a fragment of bone, and the astragalus continues in its 
outward course. If the displacement is great enough to allow the 
trochlear surface to clear the tibial articular surface, the astragalus 
will be displaced upward as well as outward and is described as 
one of the upw^ard luxations of the ankle (Dupuytren's disloca- 
tion). The more pronounced the lateral displacement of the ankle 
(until it clears the tibia) the greater the tendency of the astragalus 
to rotate on a more or less horizontal antero-posterior axis. When 
this rotation occurs the foot corresponds to the position assumed 
by the astragalus. The outer side of the foot is raised and the 
sole looks downward and outward. The surgical anatomy of this 
fracture luxation is the same as Pott's fracture (see page 659). 

In inward luxations of the ankle ("inverted" or "reversed" 
Pott's fracture) the fibula is usually fractured at the level of the 
joint and the inner malleolus is broken off at its base. The line 
of fracture in the tibia is usually oblique, extending upward and 
inward from the junction of the horizontal and vertical portions 
of the lower tibial articular surface. The usual position of the 
fracture is well illustrated in Fig. 753, The astragalus commonly 
shows more or less rotation in a direction opposite to that usually 
seen in Pott's fracture. The foot is displaced inward according to 
the degree of causative violence. Inward rotation of the foot is 
particularly common in this form of luxation. 

Backivard luxations are extremely rare and almost invariably 
accompanied by fracture. They may result from extreme plantar 
flexion of the foot or from a force ^hich drives the foot backward 
when the leg is fixed. The reverse mechanism may obtain in which 
the lower end of the leg is driven forward while the foot is fixed. 
When this type of luxation is the result of extreme plantar flexion 
the posterior margin of the tibia is almost invariably broken off. 
It is common for one or both of the malleoli to be broken off and 
displaced backward with the foot. The lower end of the tibia rests 
on the scaphoid and cuneiform bones while the astragalus is dis- 
placed backward. The ligaments of the joint suffer extensive 
laceration. If one malleolus and its corresponding lateral ligament 



DISLOCATIONS OF THE ANKLE 687 

remain intact the backward displacement will be accompanied by 
more or less of a rotary deformity with the sound malleolus as the 
center of the arc described. 

Forward luxations are extremely rare and almost invariably 
accompanied by fracture of the malleoli or the anterior edge of 
the tibia. This type of dislocation of the ankle is produced by a 
force which drives the lower end of the leg backward while the foot 
is fixed, or the same result may follow a blow on the heel which 
drives the foot forward while the leg is fixed. Extreme dorsal 
flexion, alone or combined with an antero-posterior force, may be 
responsible for the luxation. When caused by flexion the anterior 
edge of the lower end of the tibia is almost always broken off. The 
reported cases of this luxation are very few, being less than fifteen 
in all and have usually been accompanied by fracture. Most of 
the uncomplicated cases were reported before the X-ray came into 
use and some writers question the occurrence of this luxation un- 
accompanied by fracture. The case shown in Fig. 768, however, is 
a pure luxation, as demonstrated by the X-ray plate which was 
taken following reduction and which showed no fracture. 

Upward luxations of the ankle are extremely rare. Two forms 
are described. The first is simply an exaggerated Pott's fracture 
with diastasis of the lower tibio-fibular articulation and an upward 
displacement of the astragalus between the lower ends of the tibia 
and fibula. This luxation has already been described with out- 
ward dislocations of the ankle and is known as Dupuytren's lux- 
ation. The second form of upward dislocation is one in which the 
astragalus is displaced upward between the lower ends of the tibia 
and fibula following a diastasis of the tibio-fibular joint, without 
the usual complicating fracture of the fibula. 

Symptoms. — In all forms of ankle luxations the pain, tenderness, 
loss of function and swelling are usually pronounced. Ecchymosis 
often develops within twelve to twenty-four hours and is much 
more constant if the condition is accompanied by fracture. The 
deformity varies with the type of luxation. 

In outward luxations the appearance of the ankle is usually 
typical of Pott's fracture and the exaggerations of this deformity 
just described. 

In inward luxations of the ankle, the foot is usually markedly 
inverted with more or less adduction. The inner side of the foot 
is higher than normal while the outer edge of the sole is depressed. 



688 



FRACTURES AND DISLOCATIONS 



The deformity is symmetrically opposite to that seen in Pott's frac- 
ture. AYhen rotary deformity accompanies the condition it is 
usually inward, and may be as much as ninety degrees, so the 
toes point directly toward the opposite foot. 




Fig. 76'; 



Figs. 766 and 767. — Inward fracture-luxation of the ankle a few minutes follow- 
ing the injury. Inner malleolus broken off and displaced Avith the foot. The external 
malleolus remains intact. Note the prominence of the external malleolus and the way 
the skin is stretched betAveen it and the foot. Reduction accomplished without difficulty. 




Fig. 768. — Anterior dislocation of ankle. The entire tarsus is displaced forward at 
the tibio-astragaloid articulation. Note the prominence of the internal malleolus in its 
backward displacement. Injury sustained in automobile accident. Dislocation caused 
by blow on posterior aspect of heel. Trauma of vulnerant body was sufficiently great 
to penetrate counter of shoe, without, however, injuring skin on heel. Reduction easily 
accomplished by pressure in bend of ankle accompanied by traction on the foot. Picture 
taken about two hours following accident. X-ray plate taken folloAving reduction showed 
no fracture. 



In hacTxward dislocations the dorsum of the foot is shorter than 
normal and the heel is unduly prominent. The foot is usually 
held in a position of more or less pronounced plantar flexion as a 
result of the increased leverage of the muscles attached to the 



DISLOCATIONS OF THE ANKLE 689 

tendo Aeliillis. A transverse ridge is felt anteriorly, in the bend 
of the ankle, and the extensor tendons may be palpated passing 
across it from the leg to the foot. If the malleoli are not frac- 
tured they will be found displaced forward with the leg. 

In forward luxations the appearance of the foot and ankle is 
the reverse of that just described. The dorsum of the foot is 
lengthened and the heel shortened. The malleoli are both dis- 
placed backward unless broken off. The trochlear surface of the 
astragalus can, as a rule, be felt in the bend of the ankle, and when 
the usual fracture is present it may be possible to palpate the de- 
tached tibial fragment. 

In upward luxations accompanied by fracture of the fibula the 
clinical picture is that of an exaggerated Pott's fracture. Abnor- 
mal lateral mobilit}^ broadening of the malleoli, more or less ever- 
sion and crepitus are usually present on examination. The con- 
dition is often compound. When upward luxation exists without 
fracture of the fibula abnormal lateral mobility may be absent. 
The malleoli are lowered (nearer the sole of the foot) and widely 
separated. The leg above the ankle is broader than normal. 

Diagnosis. — With a knowledge of the anatomy of the parts it is 
not difficult to recognize the different types of luxation which 
occur at the ankle. The presence of complicating fracture, how- 
ever, is often not easy to determine without the aid of the X-ray. 
If the case is not seen until some hours have elapsed following the 
injury the swelling may be so intense that palpation is quite diffi- 
cult. The disturbance in the alignment of the foot and leg, as 
viewed from the side and antero-posteriorly, should be recognized 
by inspection even if the swelling is pronounced. Motion of the 
foot will usually reveal the nature of the injury. An X-ray exam- 
ination of these conditions cannot be considered complete unless 
two plates at right angles to each other are made. 

Treatment. — The nature of the injury should be appreciated by 
the surgeon before an attempt at reduction is made. There is 
usually little difficulty in returning the articular surfaces to their 
normal relations but when fracture complicates the condition, as 
it frequently does, some trouble may be experienced in maintaining 
reduction. A short plaster stirrup, as already described in the 
treatment of fractures of the tibia and fibula, is the most satisfac- 
tory method of treating these luxations but the application of this 
dressing should be delayed until the swelling (if pronounced) has 



690 FRACTURES AND DISLOCATIONS 

subsided. During this time the ankle may be treated in the pillow 
splint or fracture-box with the foot elevated and the ice cap ap- 
plied. If no fracture exists the most comfortable position for the 
foot is at an angle of about 100 degrees with the leg. In other 
words the foot should be immobilized in a position a little more 
than a right angle. If the anterior edge of the tibia has been frac- 
tured the foot should be fixed in plantar flexion, if the posterior 
edge is broken off it should be placed in dorsal flexion. In fracture 
of the malleoli there is usually little tendency to the recurrence 
of deformity if good reduction has been accomplished. In the 
treatment of Pott's fracture the foot is inverted as far as possible 
and there is no danger of overcorrecting the deformity, but in 
inward luxations of the ankle the reverse is not true. The deform- 
ity can be overcorrected and if the foot is put up in extreme ever- 
sion the result will be recovery with pronounced deformity. The 
reasons for this are apparent if we note the lines of fracture in an 
inward luxation as compared with a Pott's fracture. In an inward 
luxation the foot should be brought back into alignment with the 
bones of the leg and fixed with a plaster stirrup. 

Operative Treatment. — Operative treatment is usually not called 
for except in compound luxations and in instances in which com- 
plicating fractures cannot be satisfactorily reduced by non-oper- 
ative methods. The fragment of a fractured malleolus may become 
displaced and wedged between the astragalus and end of the tibia, 
requiring removal before proper reduction can be effected. If 
one of the malleoli or a portion of the lower end of the tibia re- 
mains displaced, in spite of attempts at reduction, it may be ad- 
visable to fix it in position through an open incision. 

Compound dislocations of the ankle should be treated along the 
lines laid down in the treatment of ''Compound Luxations" on 
page 789. The cavity of the articulation should be irrigated with 
a few gallons of sterile salt solution, devitalized tissue trimmed 
away and the wound closed. Fragments should not be wired at 
this time. If internal fixation is found necessary it should be per- 
formed at a later date after the primary wound has healed. If 
severe infection develops amputation may be necessary especially 
if the patient is old and feeble. Amputation, however, is rarely 
called for, even in compound cases, if proper surgical measures are 
carried out. 

After-Treatment. — The care of these cases following reduction 



DISLOCATIONS OF THE ANKLE 691 

varies greatly with the complications. In simple dislocations of 
the ankle without fracture, ligamentous union will be firm at the 
end of about three weeks. Function should be resumed gradually. 
Gentle passive motion should be begun at the end of ten days. 
When the condition is complicated by fracture of the lower ends 
of either the tibia or fibula the after-treatment will be practically 
the same as that already given for "Pott's fracture" (page 673) 
and in "Fracture of the Lower Ends of the Tibia and Fibula." 

Prognosis. — In simple luxations the prognosis is good but when 
fracture complicates the dislocation (as it almost invariably does) 
the outlook varies with the nature of the break. The prognosis is 
essentially that of the complicating fracture and may be considered 
the same as set down under "Fractures of the Lower Ends of the 
Tibia and Fibula," page 683, and under "Pott's Fracture," page 
673. 



CHAPTER XLIX. 

FRACTURES AND DISLOCATIONS OF THE 
ASTRAGALUS. 

When the astragalus is luxated from the navicular or the cal- 
caneum, but remains in its normal relation with the bones of the 
leg, the condition comes under the heading of Subastragalar and 
Medio-tarsal Dislocations (pages 699 and 709). When the as- 
tragalus is dislocated from the tibia and fibula, but remains at- 
tached to the tarsal bones, the condition is known as a dislocation 
of the ankle. Complete luxations, therefore, are the only displace- 
ments of this bone considered under this heading. These may be 
in any direction but are most commonl}" forward, or forward and 
outward. 

Surgical Anatomy. — The astragalus is composed of soft cancellous 
bone covered by a layer of compact tissue. The greater part of 
the surface of the bone is taken up by the articular surfaces which 




Fig. 769 



Figs. 769 and 770. — Lateral and antero-posterior views of a fracture-luxation of 
the astragalus. Fracture passes through neck of bone, the anterior fragment being dis- 
placed laterally. 



enter into the formation of the calcaneo-astragalar, astragalo- 
navicular and tibio-tarsal joints. Above, it articulates with the 
tibia and laterally the two malleoli extend downward and em- 

692 



FRACTURES AND DISLOCATIONS OF ASTRAGALUS 



693 



brace it, tlius forming the firm compact mortise of the tibio-as- 
tragahir articuhitioii which allows of motion in only one plane. 
Below, the astragalus presents two articular surfaces which enter 
into the formation of the calcaneo-astragalar joint. These two 
facets are separated by a deep groove for the attachment of the 
heavy interosseous ligament which holds the calcaneum and as- 




Fig. 771. — Antero-yostevior view of outward luxation of astragalus 
rotated on an antero-posterior axis as well as being displaced laterally. 



The bone is 



tragalus together. The anterior surface of the astragalus (the 
head) projects forward, inward and downward and articulates 
with the navicular. 

The astragalus is held in position by the conformation of the 
bones surrounding it and the heavy ligaments which bind it to the 
tibia, fibula, calcaneum and navicular. There are no muscular 
attachments on this bone. 



694 FRACTURES AND DISLOCATIONS 

In falls on the foot the astragalus may be crushed between the 
tibia and calcaneuni and is not infrequently associated with frac- 
ture of the latter bone. This type of violence, however, is much 
more likely to produce fracture of the shafts of the bones of the 
leg or fracture of the os calcis. 

In fractures of the body of the astragalus the nature of the 
break is not constant ; it may be transverse, longitudinal, or stellate, 
or the entire body may be extensively crushed and comminuted, 
with a decrease in the distance between the calcaneum and bones 
of the leg. 

Fracture of the neck of the astragalus is the most common break 
occurring in this bone and usually results from extreme dorsal 
flexion of the foot. Fractures of the neck of the bone are usually 
transverse and the head is seldom much displaced. Lateral lux- 
ations may occur with fracture of the malleoli, and backward dis- 
location of the body of the bone accompanied by fracture of the 
neck is a condition which occurs, but is extremely rare. The soft 
tissues surrounding the ankle are scant, and in the usual forward, 
or forward and outward luxation there is scarcely room within the 
skin to accommodate the bulk of the displaced bone. Accordingly 
luxations of the astragalus are often compound. In simple cases 
the skin covering the displaced bone is rendered so tense that 
sloughing is likely to follow if the displacement is allowed to remain 
unreduced. The ligamentous damage accompanying luxations of 
the astragalus is usually extensive. The displacement of this bone 
throws the foot out of alignment, and the deformity will depend 
largely on the position occupied by the astragalus. The displaced 
bone may be rotated in various directions depending largely on 
the trauma which produced the luxation. Fracture and dislocation 
may both be present in the same case. In such instances there is 
usually a fracture of the neck with luxation of either the head or 
body. 

Symptoms. — The symptoms accompanying fractures and disloca- 
tions of the astragalus vary greatly with the nature and degree 
of the injury. Fractures of this bone, especially of the body, have 
frequently been mistaken for sprains of the ankle and treated ac- 
cordingly. In fractures of the body, pain, swelling and disability 
are pronounced. Motion of the ankle and attempts at weight bear- 
ing greatly increase the suffering. Crepitus may, or may not, be 
present. It is usually best elicited by palpation in the bend of 



FRACTURES AND DISLOCATIONS OF ASTRAGALUS 695 

the ankle while the foot is being passively flexed and extended. 
Fracture of the neck of the astragalus is usually attended by symp- 
toms a little more pronounced than is the case in fractures of the 
body. Pain, loss of function, swelling and local tenderness are 
generally severe and crepitus is, as a rule, easily elicited by lateral 
motion of the foot. Deformity, if present at all, is usually very 
slight in either fracture of the body or neck. 

In luxations of the bone loss of function, pain, swelling and 
local tenderness are equally as pronounced as in fracture, and the 
deformity is usually extreme. In any of the forward displace- 
ments the bone may be felt as a prominent mass in the bend of the 
ankle, the foot is more or less depressed and the malleoli are 
lowered. AYhen the astragalus is displaced forward and outward 
the foot will be inverted. When the bone is luxated forward and 
inward the foot will be everted. In backward luxations of the bone 
(practically alwaj^s associated with fracture of the neck) the body 
may be felt between the lower end of the tibia and the tendo 
Achillis, and an abnormal hollow will be noted anteriorly, below 
the lower end of the tibia. Lateral luxations are associated with 
fractures of one or both malleoli, are usually incomplete and re- 
semble lateral dislocations of the ankle. 

Diagnosis. — The diagnosis of these different lesions is based on 
the symptoms just given. Fractures of the astragalus are often 
difficult to determine unless crepitus can be elicited and even then 
the surgeon's appreciation of the condition is likely to be vague if 
the case is not examined with the X-ray. The deformity in lux- 
ations is usually sufficiently pronounced to permit of recognition 
of the condition. The association of fractures of the different 
bones of this region is so frequent that the X-ray should be em- 
ployed whenever available. By its use complicating lesions are 
often shown to exist, w^iich would otherwise be overlooked. 

Treatment. — The traumatic reaction is often severe during the 
first few days or week in fractures of this bone and during this 
time it is advisable to treat the leg in the pillow splint, in the ele- 
vated position and with the intermittent use of the ice cap. When 
the swelling has subsided the foot and ankle may be fixed in a 
short plaster stirrup after the parts have been properly covered 
with sheet cotton to provide the necessary padding. The best 
reduction is usually had in a position of slight plantar flexion, 
which position is preferable in most cases to the academic ''right 



696 FRACTURES AND DISLOCATIONS 

angle," so insistently and uselessly demanded in most text -books. 
If the condition is accompanied by other fractures in the foot a 
more complete fixation may be required, and is had by means of a 
short posterior plaster splint. This splint is applied before the 
stirrup and extends down the leg and under the foot to a point 
just beyond the toes. It is the same as used in fractures of the 
metatarsals. 

In dislocations of the astragalus reduction should be effected at 
the earliest possible moment, unless the condition is compound. 
The necessary manipulations will depend entirely upon the posi- 
tion occupied by the displaced bone. The object is to return the 
trochlear surface of the astragalus to its proper relation in the 
mortise formed by the tibia and fibula. This may be a difficult 
matter especially if rotation of the bone has occurred. The fact 
that no tendons are inserted into the astragalus increases the difii- 
culty of reduction. 

In forward displacements of the bone, direct backward pressure 
on the prominent trochlear surface will usually effect reduction. 
Plantar flexion before the bone is ''started," and dorsal flexion in 
the latter part of the manipulation may aid materially in reduction. 

In the forward and outward type of luxation similar maneuvers 
are employed. The common outward rotation of the bone is often 
difficult to correct, and until it is, it will usually be impossible to 
effect reposition. Strong traction on the foot and sometimes an 
accentuation of the inversion will render the direct pressure more 
efficient. 

In inward and forward luxations the opposite manipulations 
are necessary to return the bone to its normal position. 

In backward luxations with the usual fracture of the neck, strong 
traction with direct forward pressure on either side of the ankle 
in front of the tendo Achillis, will usually be sufficient to accom- 
plish reduction. Plantar flexion of the foot while traction is being 
made, will increase the distance between the calcaneum and the 
tibio-fibular mortise posteriorly and may thus facilitate reduction. 
If reduction cannot be accomplished by manipulation, open incision 
under proper surgical surroundings should be resorted to at once. 
This is particularly true of any of the anterior luxations, since the 
pressure exerted by the displaced bone may produce sloughing of 
the integument and render the condition compound. The fact 
that the trochlear surface is slighth' broader anteriorly accounts 



FRACTURES AND DISLOCATIONS OF ASTRAGALUS 697 

for the frequency of complicating fractures of the malleoli in back- 
ward luxations. AYlien either of the malleoli are broken they de- 
serve special consideration in the treatment (see "Pott's Frac- 
ture," page 66S, and "Dislocations of the Ankle," page 689. The 
treatment of lateral dislocations with fracture of the malleoli is 
similar to that already given for lateral luxations of the ankle. 
When either fracture or luxation of the astragalus is compound, 
immediate operative intervention is demanded. 

Operative Treatment. — Operation is seldom indicated in the 
treatment of simple, uncomplicated fractures of the astragalus. 
It is called for in compounci cases and in instances in which lux- 
ations of the bone cannot be immediately corrected by manipula- 
tion. In compound cases no attempt at reduction should be made 
until the patient is in the operating room. The skin should be 
painted with a five percent tincture of iodine, lacerated and de- 
vitalized tissue should be trimmed away from the margin of the 
wound and the cavity irrigated with a few gallons of sterile salt 
solution. The surgeon then determines what the individual needs 




Fig. 772. — Deformed astragalus removed to restore function. Old fracture with 
union in deformity. 

of the case may be. Fractures usually require nothing in the way 
of reduction, and internal fixation of the fragments is not feasible. 

In luxations the bone is to be returned to its normal position by 
direct manipulation while traction, flexion, extension or other 
needed maneuvers of the foot are carried out. Care should be 
exercised to avoid injury to the articular surfaces while grasping 
the bone with forceps. The best place to grasp the astragalus and 
one in which the teeth of the forceps will do no damage, is at the 
neck. 

The wound is then closed with interrupted sutures. If diffi- 
culty is experienced in bringing the edges of the wound together, 
after the devitalized tissue has been removed, it may be necessary 
to perform some plastic, skin-sliding operation. It is imperative 



698 FRACTURES AND DISLOCATIONS 

that the wound be closed at this time, even at the expense of leaving 
some adjoining area denuded. If suppuration occurs in spite of 
this treatment (and it rarely does) drainage will be necessary. 

Excision of the bone in difficult cases was the usual treatment a 
few years ago but at the present time there seems to be no excuse 
for this procedure, except in the most extreme cases. In old un- 
reduced luxations, and in recent cases in which necrosis develops 
in the astragalus it may be necessary to excise the bone, either en- 
tirely or in part. In instances in which ankylosis of the tibio- 
tarsal articulation follows suppuration surprisingly good function 
may be restored by a spontaneous increase in the range of motion 
in the medio-tarsal articulation. 

After-Treatment. — In fractures of the astragalus due time should 
be allowed for proper union of the fragments. It should be re- 
membered in this respect that the strain entailed in ordinary walk- 
ing is considerable, and unless the callus is well ossified and solid, 
deformity may follow. The foot should be protected from weight 
bearing until two months or more have elapsed from the time of 
the injury and even then function should be only gradually re- 
sumed. Massage and early passive motion, however, are essential 
in preventing joint adhesions, and if properly employed, subject 
the parts to very slight strain. 

The resumption of function may be begun at the end of four 
or five weeks in simple luxations. Complicating fractures of ad- 
joining bones modify the after-treatment according to the nature 
of the lesion. 

Prognosis. — In simple luxations of the astragalus, with proper 
and prompt reduction, we may look for practically complete res- 
toration of function. The outlook in fractures depends on the 
severity of the lesion and is not generally as favorable as is the 
case in simple dislocations. Recovery is slower and ultimately 
some restriction in motion may exist. Simple transverse fracture 
of the neck is usually followed by better results than is usual with 
fractures of the body. 

In instances in which luxations have been allowed to go un- 
treated the loss of function and deformity are usually pronounced. 
Surprisingly good function, however, frequently follows complete 
removal of the bone. 



CHAPTER L. 

SUBASTRAGALAR LUXATIONS. 

Surgical Anatomy. — The astragalus rests upon, and articulates 
with, the ealeaneum by two facets which are divided by a deep 
groove for the attachment of the heavy interosseous ligament. 
The ealeaneum and astragalus are directly bound together by the 
internal, external and posterior calcaneo-astragaloid ligaments and 
by the interosseous ligament. Both the internal and external 
lateral ligaments of the ankle-joint are attached below to the eal- 
eaneum as well as the astragalus, and in subastragalar luxations 
either of the malleoli may be broken by the direct pull of these 
ligaments. The relatively low position of the external malleolus 
exposes it to fracture by direct pressure of the ealeaneum when the 
luxation is outward. The only ligament passing between the as- 
tragalus and navicular is the superior astragalo-navicular which is 
thin and weak. The place of the lower ligament is taken by the 
calcaneo-navicular ligament. This ligament, by binding the eal- 
eaneum to the navicular, maintains the head of the astragalus in 
apposition with the navicular. 

In subastragalar dislocations the ealeaneum may be displaced 
inward, outward, backward or forward. The astragalus remains 
in position in the tibio-fibular mortise while the bones of the tarsus 
below it are displaced as a whole. The most common luxation is 
lateral, oblique, incomplete and often compound. The displace- 
ment is usually more complete in the posterior subastragalar joint 
than in the anterior. The head of the astragalus is, as a rule, com- 
pletely separated from the navicular. There is often slight back- 
ward displacement accompanying either the inward or outward 
luxation. Forward luxations are extremely rare, resembling in 
this respect forward dislocations of the ankle-joint. The articula- 
tion between the head of the astragalus and the navicular is almost 
invariably broken up in subastragalar luxations regardless of the 
direction in which the foot is displaced. 

The usual subastragalar luxation is the result of forcible inver- 
sion or eversion of the foot and not infrequently occurs in falls 

699 



700 



FRACTURES AND DISLOCATIONS 



on the foot. This type of violence is much more likely to produce 
fracture-luxations of the ankle than dislocations of the subastraga- 
lar articulation. Fracture of the neck of the astragalus is a com- 
plication which has been recorded in a number of cases. 

Symptoms. — In outward luxations the sole of the foot looks down- 
ward and outward and the w^hole foot is displaced laterally. The 




Figs. 773 and 774. — Case of backward dislocation of the calcaneum and scaphoid on 
the astragalus. (Backward subastragalar luxation.) The calcaneo-astragalar joint has 
been dislocated and the articulation between the astragalus and navicular has been 
entirely broken up. The head of the astragalus is seen presenting in the wound with 
the tendon of the tibialis anticus lying internal to it. Result of falling down an elevator 
shaft. The foot below the astragahis is displaced backward. Note the prominence of 
the heel. 



inner malleolus is abnormally prominent and the head of the as- 
tragalus ma}^ be palpated. The malleoli are in normal relation 
with each other and with the astragalus, which is not displaced 
with the foot. The external malleolus is less prominent than nor- 



SUBASTRAGALAR LUXATIONS 701 

mal. If backward displacement of the foot exists, as Avell as lateral, 
there will be an undue prominence of the heel and a corresponding 
shortening of the dorsum of the foot. 

In inward luxations the reverse deformity is seen. The sole of 
the foot looks downward and inward. The inner border is raised 
and more concave than normal. The external malleolus is unduly 
prominent. The head of the astragalus may be palpated and the 
scaphoid may be felt near the inner malleolus. The whole foot is 
displaced inward. Antero-posterior luxations resemble disloca- 
tions of the ankle in the same plane. The fact that the astragalus, 
however, remains in its normal relation with the bones of the leg 
causes the deformity to be at an obviously lower level than that 
seen in dislocations of the ankle. 

In posterior luxations the dorsum of the foot is shortened and 
the heel abnormally prominent. The head of the astragalus pro- 
jects into the bend of the ankle and may be readily recognized in 
this position. The condition may be compound as shown in Figs. 
773 and 774. 

Anterior luxations are extremely rare. The heel is shortened 
and the dorsum of the foot lengthened. Palpation reveals the 
astragalus in its tibio-fibular mortise. 

Diagnosis. — The diagnosis of these luxations is based on the 
characteristic deformities just described. If the swelling is in- 
tense it may be difficult to recognize the exact nature of the de- 
formity. An X-ray is of the greatest value in ascertaining the 
details of the injury. 

Treatment. — There is seldom much difficulty in reducing the 
deformity. In the lateral luxations the surgeon secures a firm 
grasp of the heel with one hand and the dorsum of the foot with 
the other, and by strong traction the foot is brought back into 
position. Counter-traction will usually be needed and should be 
made by an assistant, above the ankle. In backward luxations for- 
ward traction should be exerted on the heel while the leg is fixed. 
The reverse manipulation is performed to correct anterior lux- 
ations. The parts should be fixed in a plaster cast extending from 
the middle of the leg to the toes and cut open before the plaster 
has dried. 

Operative Treatment. — If reduction cannot be performed by 
manipulation, open incision with direct reposition of the displaced 
bones should be performed. 



702 FRACTURES AND DISLOCATIONS 

After-Treatment. — Firm union of the lacerated ligaments will be 
present at the end of two and a half to three weeks. Passive motion 
should be begun at the end of ten days but the patient should not 
be allowed to bear his weight on the foot inside of three weeks 
from the time of the accident. 

Prognosis. — The loss of function following this accident is very 
trivial if proper reduction of the displacement has been accom- 
plished following the injury. Like dislocations in other joints, 
the too early use of the parts is likely to be followed by recurrence 
of the luxation which mav even become habitual. 



CHAPTER LI. 

FRACTURES AND DISLOCATIONS OF THE 
CALCANEUM. 

Surgical Anatomy. — Fracture of the os calcis is a fairly common 
accident but isolated luxations of this bone are extremely rare. 
The internal structure of the bone is cancellated while the surface 
is composed, for the most part, of a thin layer of compact tissue. 
The surface layer is heavier on the external, lateral surface of the 
bone than elsewhere. The os calcis articulates above with the 
astragalus by two facets, which are divided by a deep groove for 
the attachment of the heavy interosseous ligament binding these 
two bones together. The anterior extremity of the calcaneum ar- 
ticulates with the cuboid which in turn supports the fourth and 
fifth metatarsal bones. The os calcis is connected by ligaments 
with the astragalus, cuboid, navicular and to the second, third and 
fourth metatarsal bones. A number of the intrinsic muscles of 
the foot, as well as one of the secondary insertions of the tibialis 
posticus, are attached to the calcaneum but the muscles of surgical 
importance finding attachment on this bone are the gastrocnemius 
and soleus. These muscles are inserted through their common 
tendon, the tendo Achillis, into the lower part of the posterior 
surface of the bone. The fact that this tendon is inserted into the 
lower and not the upper part of the posterior surface accounts for 
the peculiar displacement of the fragment when fracture results 
from muscular action. 

A small anomalous bone (the trigonum) is sometimes present 
just behind the posterior subastragalar joint, and if one is not 
familiar with its appearance it may be mistaken for a fracture, in 
interpreting an X-ray plate (see Fig. 776). The os calcis is ossi- 
fied by two centers : one for the main portion of the bone, and the 
other for the epiphysis. That for the body makes its appearance 
during the sixth foetal month. The center for the epiphysis is 
first seen during the tenth year and joins the body of the bone 
soon after puberty. It should not be mistaken, during this period, 
for a fracture of the posterior portion of the bone. 

703 



704 



FRACTURES AND DISLOCATIONS 



Fracture of the calcaneum may result from falls on the foot, 
from muscular contraction and from forcible twisting of the foot. 
The fracture may be transverse, or longitudinal, and not infre- 
quently extensive comminution of the bone exists. Any portion 
of the bone may be broken and the posterior part is often displaced 




Fig. 775. 

Fig. 7 75. — Fracture of calcaneum. 

Fig. 776. — Anomalous bone present (the trigonum) which might readily be mistaken 
for a fracture. 




Fig. 777. — Fracture of calca;neum. 



Fiii-. 



-Fracture of calcanenni. 



outward as w^ell as upward. The usual break is produced by a fall 
from a height in which the patient lands on the foot. There is 
usually more or less comminution and crushing of the bone below 
and behind the astragalus, and not infrequently the line of frac- 
ture enters the posterior subastragalar articulation. This com- 



FRACTURES AND DISLOCATIONS OF CALCANEUM 705 

mimition results in an increase in the width of the bone. Twisting 
of the foot and falls on the foot while inverted are said to be pro- 
ductive of fractures of the sustentaculum tali. 

When fracture results from a twist of the foot the line of the 
break is more clean cut and the deformity is, as a rule, slight. 

When fracture occurs as the result of overaction of the calf 
muscles the line of the break and the deformity are usually charac- 
teristic. A small fragment is detached from the posterior portion 
of the bone and displaced upward by the pull of the tendo Achillis. 
The upper end of the fragment commonly remains in contact with 
the body of the calcaneum while the lower end describes an arc 
upward and backward. 

Isolated dislocation of the calcaneum is an extremely rare con- 
dition and is essentially the same as an incomplete subastragalar 
luxation. The bone is torn away from its attachments to the 
astragalus and cuboid and is most often displaced outward. The 
symptoms and treatment are practically the same as that given 
under the heading of "Subastragalar Luxations," page 700. 

Symptoms. — The patient complains of pain in the region of the 
injury particularly Avhen an attempt is made to stand on the foot. 
If weight is placed on the heel the direct pressure produces suf- 
fering. If the weight is placed on the ball of the foot the action 
of the calf muscles will pull upward on the calcaneum and the at- 
tempt will be equally painful. Swelling usually develops promptly 
following the accident and is noted on either side of the foot below 
the ankle, especially to the inner side. The foot often gives the 
appearance of flat-foot. The heel is broadened, elevated and often 
displaced outward. If there has been much comminution of the 
calcaneum its width will be increased and the outward displace- 
ment of the external wall may be recognized by palpation below 
the external malleolus. Flexion and extension of the ankle will 
be free but lateral motions of the foot involving the tarsal joints 
will be restricted, especially if the fracture has entered the pos- 
terior subastragalar articulation as it so frequently does. Crepitus 
can usually be elicited by manipulating the heel but it is never 
sharp and pronounced. This is explained by the small amount of 
compact tissue in the calcaneum. 

In luxations of the calcaneum the heel is displaced as a whole, 
either inward or outward. There is abnormal mobility, no crepitus 
and no upward displacement as in fracture. 



706 FRACTURES AND DISLOCATIONS 

Diagnosis. — The diagnosis is based on the preceding symptoms 
but should be confirmed by the X-ray. This renders the diagnosis 
certain, informs the surgeon of the exact nature of the fracture 
and discloses complicating injuries of adjoining bones when they 
occur. Notwithstanding the great differences in the symptoms of 
the two conditions, fracture of the os calcis has been mistaken for 
Pott's fracture, in a number of instances of which the author 
knows. The normal positions and relations of the malleoli and 
the position of the astragalus in the tibio-fibular mortise should 
serve to differentiate this condition from lesions higher up. Im- 
pacted fracture of the os calcis may be quite difficult to recog- 
nize without the aid of the X-ray. If a stereoscopic Rontgenogram 
is made it will aid the surgeon materially in appreciating the de- 
formity. There is considerable variation in the normal contours 
of different calipanea and it is therefore advisable to have a plate 
made of the opposite foot for the sake of comparison. 

Treatment. — The treatment of fracture of the os calcis is to 
immobilize the foot in a position which will correct the deformity. 
Complete plantar flexion of the foot relieves, to a large extent, the 
displacing pull of the calf muscles inserted through the tendo 
Achillis. Fixation is usually best accomplished by means of a 
short, well padded, plaster stirrup. While the plaster is setting 
the surgeon should hold the bone in reduction ; this can be done by 
grasping the heel and pulling it downward and slightly inward. 
The stirrup is moulded tightly about the tendo Achillis at the back 
of the ankle and when the plaster is firmly set prevents upward 
displacement of the posterior end of the calcaneum. The portion 
of the stirrup passing under the foot should be so moulded that it 
supports the arch of the foot. Reduction and fixation can, as a 
rule, be satisfactorily accomplished in this way. If, however, the 
pull of the calf muscles proves greater than can be overcome by 
this dressing a tenotomy of the tendo Achillis may be required to 
prevent recurrence of deformity. "When considerable broadening 
of the calcaneum exists as a result of crushing of the bone it may 
be necessary to force the sides of the bone toward each other by 
lateral pressure beneath the malleoli. If the surgeon has a power- 
ful grip this may be accomplished manually. An anesthetic should 
be employed to correct the deformity and apply the plaster stirrup. 

Operative Treatment. — Aside from tenotomy (which is rarely 
needed) operation is called for in compound cases, and in instances 



FRACTURES AND DISLOCATIONS OF CALCANEUM 707 

in which the fragment has been detached and displaced upward by 
the pull of the calf muscles. Compound fracture of the calcaneum 
is to be treated according- to the principles laid down on page 789. 
In severe crushing injuries, with destruction of the soft tissues 
covering the calcaneum, plastic operations and skin grafting may 
be called for to cover the bone. Necrosis may require sequestrot- 
omy. 

If a fragment, displaced by the tendo Achillis, is not readily 
held in position by pads (and it seldom is), operation with direct 
fixation of the fragment is indicated. Nailing of the fragment is 
not advisable because of the soft cancellous tissue in which the 
nail must be placed. A small mattress suture, preferably of silver 
wire, is probably the best method of securing the fragment in 
position. 

Outward displacement of the external surface of the bone may 
give rise to an extremely tender point below the outer malleolus, 
when the patient resumes the use of the foot. This may call for 
removal, by chiseling, of the portion of bone impinging against the 
inner side of the malleolus. The formation of excessive callus in 
this region may produce the same symptoms and calls for similar 
treatment. A fragment or spicule of bone projecting into the sole 
may render walking excessively painful and calls for removal of 
the offending portion of bone after the diagnosis has been con- 
firmed by the X-ray. Union with extreme deformity may be fol- 
lowed by such pronounced disturbances in function that operation 
is demanded for the relief of the condition. A transverse oste- 
otomy of the calcaneum just behind its articulation with the 
astragalus, with correction of the deformity, should be done. 

Operative treatment is not indicated in uncomplicated luxations 
of the calcaneum. 

After-Treatment. — Union takes place rapidly in the calcaneum 
but it should be remembered that the strain imposed on the bone 
in walking is great, and unless the callus is solidly ossified sec- 
ondary deformity may develop. 

By means of a properly applied plaster stirrup the foot is im- 
mobilized for a period of from four to six weeks. Passive motion 
and gentle massage should be instituted at the end of two weeks. 
No weight should be borne on the injured foot within two or tAVO 
and a half months and the resumption of function should be grad- 
ual. If the fracture has been a severe one this time mav be 



708 FRACTURES AND DISLOCATIONS 

increased. Secondary upward displacement of the heel and the 
development of static flat-foot are the results of too early use of 
the foot in walking. Free active and passive motion are of advan- 
tage in the treatment of the case many weeks before it is safe to 
allow the full weight to be borne on the injured member. In cases 
in which the calcaneum has united in deformity a pad may be 
worn in the shoe beneath the heel and will often afford great com- 
fort. In instances in which traumatic flat-foot occurs arches may 
be worn within the shoe to support the inner side of the foot. 
These measures, however, are poor substitutes for union with the 
fragments in proper position, and will seldom be needed if the 
deformity has been properly corrected and held in reduction fol- 
lowing the injury. 

Prognosis. — AYith proper treatment uncomplicated fracture of 
the OS calcis should be followed by fair restoration of function. 
The most important sequelse are : flat-foot, restriction of motion in 
the subastragalar articulation, metatarsalgia, pain beneath the 
outer malleolus, and painful heel caused by a projecting fragment. 
The more perfectly the deformity is corrected following the acci- 
dent the less the probability of these annoying and disabling 
sequelag. Occasionally, however, a case is seen in which the most 
perfect reduction and painstaking after-treatment have been car- 
ried out and yet there is considerable disturbance in function as a 
result of one or more of these conditions. Flat-foot may be treated 
by means of arches within the shoe or if severe an osteotomy of the 
calcaneum may be performed and is usually followed by pro- 
nounced improvement. The motion in the subastragalar articu- 
lation may be increased by forcible passive motion under anesthesia, 
which may be repeated many times if necessary. Metatarsalgia is 
a result of flat-foot and will pass off with removal of the cause. 
Pain beneath the outer malleolus is relieved by removing the por- 
tion of bone causing the pressure. Removal of spurs on the under 
surface of the calcaneum will be followed by prompt and complete 
relief. Considering the causes of disturbed function and the pos- 
sibility of relief the prognosis is not so bad provided the patient 
is willing to submit to the necessarv corrective measures. 



CHAPTER LII. 

MEDIO-TARSAL LUXATIONS. 

Surgical Anatomy. — Luxations sometimes, though rarely, occur 
at the medio-tarsal joint, the anterior portion of the foot being 
more or less completely displaced from the posterior. The bones 
entering into the articulation are proximally the astragalus and 
calcaneum, and distally the navicular and cuboid. The ligaments 
connecting these bones are very powerful and the articulation is 
seldom broken up except in crushes of the foot. The inner portion 
of this joint is a part of the anterior subastragalar articulation. 
The outer part of the joint (the calcaneo-cuboid) has a separate 
synovial cavity. The pliability of the foot depends mainly on the 
subastragalar and medio-tarsal articulations. Luxations of the 
medio-tarsal articulation have been so confounded with subastraga- 
lar luxations that only a few of the reported cases can be con- 
sidered sufficiently dependable to deserve consideration. Disloca- 
tion, uncomplicated by fracture, rarely if ever occurs. The 
displacement may be inward, downward or outward. Upward 
luxation of the bones probably occurs only as a secondary element 
in outward luxations. In most of the cases the deformity has 
resembled that of an inward subastragalar luxation. The anterior 
portion of the foot is shortened, the inner border raised and more 
concave than normal. The calcaneum is not deviated as in sub- 
astragalar luxations. Crepitus is usually present as a result of 
complicating fracture. The anterior portion of the foot is abnor- 
mally mobile. The anterior ends of the calcaneum and astragalus 
produce a distinct ridge on the dorsum of the foot. 

In outward luxations the foot is pronated and the scaphoid and 
cuboid slightly raised. 

Treatment. — The treatment consists in reducing the luxation and 
immobilizing the parts sufficiently long to allow healing of the liga- 
ments. Reduction should be accomplished by open incision if non- 
operative measur(;s fail. The treatment, operative treatment, after- 
treatment and prognosis are similar to those given under "Sub- 
astragalar Luxations," page 699. 

709 



CHAPTER LIII. 

FRACTURES AND LUXATIONS OF THE CUBOID, 
SCAPHOID AND CUNEIFORMS. 

Surgical Anatomy. — The cuboid articulates with the calcaneum 
posteriorly and to the inner side with the external cuneiform. It 
supports the outer tw^o metatarsals and is securelj^ held in position 
by heavy ligaments connecting it with the adjoining bones. Frac- 
ture of the cuboid is not an uncommon lesion, especially in crushing 
injuries of the foot, but isolated luxation of this bone is hardly 
more than a surgical anomaly. Fracture usually results from di- 
rect violence to the dorsum of the foot and since the bone is prac- 
tically subcutaneous the condition is often compound. The three 
cuneiforms are firmly bound together and to the surrounding bones 
by heavy ligaments and like the cuboid are rarely luxated. Frac- 
ture of these bones is usually the result of direct violence. Cases 
of partial displacements of the navicular and cuneiforms have been 
reported but the mechanism is not clear. It should be remembered 
that the tibialis anticus and tibialis posticus, two powerful mus- 
cles, find their main insertions on the cuneiforms and navicular. 

The cuboid, navicular and cuneiforms are all composed of can- 
cellous tissue internally, while the surface is made up of a thin 
layer of compact bone. They are firmly bound together by heavy 
ligaments and are usually fractured by direct violence to the 
dorsum of the foot. The soft tissues covering the dorsum of the 
foot are scant and the lesion is often compound. AVhen the frac- 
ture is not compound from the first, it often becomes so later, as a 
result of sloughing of the integument on the dorsum of the foot. 

A crushing of the tarsal or metatarsal bones is an accident not 
uncommonly seen among railroad employees. The foot is caught 
beneath the wheels of a car and more or less severely crushed. If 
the train is moving with much speed the foot is crushed and ampu- 
tated. If the rate at which the train is moving is slow the foot 
may be pushed aside and only partially crushed. 

Treatment. — In fractures of the anterior bones of the tarsus, 

710 



FRACTURES AND LUXATIONS OF CUBOID AND SCAPHOID 



711 



Avhatever deformity is present should be corrected and the foot 
immobilized on a plaster sole as shown in Fig. 787. This splint 
should extend from the middle of the leg to a point beyond the 
toes. A plaster cast should not be used since secondary sloughing 
is not uncommon and the skin on the dorsum of the foot should be 




Figs. 779 and 780. — Crushing injuries of feet sustained beneath car-wheels. Crush- 
ing disarticulation through tarso-metatarsal joint. In the upper plate (Fig. 779) the 
lower portion of the foot is not completely severed though the tissues are so thoroughly 
mangled that the circulation is destroyed and amputation is necessary. In the lower 
plate (Fig. 780) the lower portion of the foot was completely severed at the time of 
the accident. 



open to inspection during the after-treatment. The damage to the 
soft tissues is often more important than the fracture. If slough- 
ing occurs the parts should be frequently dressed and the sloughing 
area kept as aseptic as possible. Granulations should be cultivated 
and stimulated by balsam of Peru and in removing the dressings 
the surgeon should avoid injury to these delicate granulations. 



712 FRACTURES AND DISLOCATIONS 

The use of antiseptics such as bichlorid of mercury will do more 
harm than good. While healing and union are taking place the 
surgeon should see to it that the plaster sole properly maintains 
the arch of the foot. 

Operative Treatment. — Operation is frequently indicated because 
the fracture is compound but rarely to accomplish reduction. The 
treatment of compound cases is the same in fractures of these bones 
as has already been indicated under the heading of "The Treat- 
ment of Compound Fractures" on page 789. In severe crushes 
of the foot immediate amputation is not infrequently demanded. 

After-Treatment. — The length of the period of immobilization 
varies greatly with the severity of the fracture and whether or not 
it is compound. If the arch of the foot has been involved, by the 
fracture or luxation, weight should not be borne on the injured 
member inside of six weeks. In instances in which this has not 
occurred the patient may begin the gradual resumption of func- 
tion at the end of three or four weeks. If sloughing of the tissues 
on the dorsum of the foot takes place union is usually delayed and 
the period of fixation should be prolonged accordingly. 

Prognosis. — In severe crushes of the foot amputation may be 
necessary. In instances in which the trauma has not been severe, 
with little displacement, and no sloughing of the soft tissues, com- 
plete restoration of function is the rule. Surprisingly good func- 
tion not infrequently follows even in compound cases and in 
instances in which the soft tissues have sloughed. 



CHAPTER LIV. 
TARSO-METATARSAL LUXATIONS. 

Surgical Anatomy. — The articulation between the distal tarsals 
(three cuneiforms and cuboid) and the bases of the five metatar- 
sals is firmly supported by heavy ligaments, and luxations are 
rare. Displacements of the bases of the metatarsals may occur, 
but the causative trauma is more likely to produce fracture in this 
region. The anterior end of the long plantar ligament is attached 
to the bases of the second, third and fourth metatarsals. All five 
metatarsals may be luxated as a row, or the base of any one may 
be dislocated alone. The displacement is almost invariably dorsal, 
so that the base of the metatarsal may be palpated on the dorsum 
of the foot. Luxation of the first metatarsal alone is the most 
common single luxation. The dorsum of the foot is slightly short- 
ened. Divergent luxations have been noted in which the bases of 
the outer metatarsals are displaced outward, while the inner bones 
of this row are displaced inward. 

Symptoms. — The dorsum of the foot is slightly shortened, and a 
little more prominent than normal. Pain is experienced in walk- 
ing and when pressure is made on the ball of the foot by the sur- 
geon. Crepitus is absent unless the luxation is accompanied by 
fracture, which is not uncommon. If the foot is carefully com- 
pared with the opposite foot the deformity will be noted at the 
level of the tarso-metatarsal articulation. Pressure on the ball of 
the foot may increase the deformity on the dorsum, as the corre- 
sponding metatarsal is displaced upward and backward. 

Diagnosis. — If swelling is pronounced it may be difficult to differ- 
entiate between luxations of this joint and fractures of the ad- 
joining bones, without the aid of the X-ray. When the traumatic 
reaction is not great the landmarks on the foot will serve to dis- 
close the nature and position of the lesion. 

Treatment. — Traction on the foot will accomplish reduction. The 
foot should be fixed for a period sufficiently long to allow healing 
of the ligaments. The treatment of luxations at this joint is simi- 
lar to other dislocations in the tarsus. 

713 



CHAPTER LA^ 

FRACTURES OF THE METATARSALS. 

Surgical Anatomy. — The metatarsal bones are classed among the 
long bones. The extremities are composed largely of cancellous 
tissue encased in a thin layer of compact bone. The shafts consist 
of a heavy tube of compact tissue. Accordingly, the nature of the 
fracture varies with the region of the bone broken. The outer four 
metatarsals are ossified by two centers, one for the shaft and one 
for the head (the distal end). That for the shaft appears about 
the seventh week, while the epiphyseal center is first seen during 
the third year. Ossification of the epiphyseal cartilage occurs be- 
tween the eighteenth and twentieth years. The first metatarsal is 
different from the other four. The head and shaft are ossified 
from one center which makes its appearance in the seventh week. 
The base is the epiphysis and its center is first seen during the 
fifth year. Fusion occurs between the eighteenth and twentieth 
years. Not uncommonly there is also an epiphysis for the head of 
the bone. AVhen the first metatarsal shows two epiphyses it re- 
sembles both metatarsal and phalanx. These facts concerning the 
ossification of the metatarsals are of importance in examining 
Rontgenograms of this region in persons under twenty years of age. 

The bases of the metatarsals are firml}- bound to the distal tar- 
sals and to each other by heavy ligaments, and like the tarsals are 
seldom luxated. The long plantar ligament is attached to the 
ventral aspect of the bases of the second, third and fourth meta- 
tarsals. The distal ends of the metatarsals do not articulate with 
each other but are held in position by the transverse metatarsal 
ligament. This ligament tends to prevent overriding deformity of 
the shaft in the presence of fracture of one of the metatarsals. 
Aside from the tendons of the long extensors playing over the 
dorsum of the foot the metatarsals are practically subcutaneous. 
The scant, soft tissues covering the bones in this region offer little 
protection from direct violence when applied to the dorsum of the 
foot. 

714 



FRACTURES OF THE METATARSALS 



715 



Fractures of the metatarsals are almost invariably the result of 
direct blows and are frequently seen in crushes of the foot. Frac- 
ture from indirect violence does, however, occasionally occur, espe- 
cially of the first and fifth. A misstep or twist of the foot may 




Fig-. 782. 
Figs. 781 and 782. — Show fractures of the bases of the fifth metatarsals. 

produce fracture of one of the metatarsals. The injury has been 
noted in soldiers at the end of long, forced marches. The base of 
the fifth metatarsal is prominent, and falls on the foot, with the 
member inverted, not uncommonly result in fracture of the 



716 



FRACTURES AND DISLOCATIONS 



proximal portion of this bone. Fracture of the metatarsals is not, 
as a rule, accompanied by impaction and displacement, as is the 
case when the metacarpals are broken. 




Fig. 783. 



784. 



Fig. 783. — Oblique fracture of the shaft of the fifth metatarsal. 
Fig. 784. — Fracture of the b'ase of the fifth metatarsal. 




Fig. 785. — Compound crushing injury of metacarpus in -n-hich eight distinct frac- 
tures may be seen. Result of eight-ton girder falling on foot. Same case as shown in 
Fig. 787. 

Symptoms. — The symptoms vary greatly with the severity of the 
injur}\ In cases produced by comparatively slight trauma, and 
in those due to muscular action the symptoms will be moderate 



FRACTURES OF THE METATARSALS 



717 



and more or less typical. In severe crushes of the foot it is not 
uncommon to be able to see the fractured bones in among the 
lacerated and mano-led tissues of the foot. In such instances the 




Fig. 786. — Method of detecting fractures in the metacarpals. Pressure on the 
metacarpal head in the line of the long axis of the bone will elicit pain in the presence 
of fracture. 




Fig. 787. — Crushing injury of the foot. An eight-ton girder fell on the foot as it 
was resting on the edge of a curb, prodaciug eight fractures in the metacarpal bones. 
(See X-ray, Fig. 785.) The wound seen in the plate resulted from subsequent slough- 
ing and it was possible at one time to see four of the fractures of the metatarsals. Wound 
healed by cultivation of granulation tissue rather than attention to antisepsis. Result: 
union in all the fractures with closure of the wound and perfect recovery of function. 
Patient walks without limp. 



fractures present are only of secondary importance as compared 
with the damage done to the soft parts. Sloughing of the tissues 
on the dorsum of the foot is not an uncommon sequel when the 
causative trauma has been severe and direct. In crushes of the 



718 FRACTURES AND DISLOCATIONS 

foot there will, of course, be complete loss of function. In simple 
cases pain, tenderness, swelling, crepitus and abnormal mobility 
will be present. The suffering is increased if the patient attempts 
to stand on the foot, and in some instances the fragments may be 
heard grating against one another as the attempt is made. De- 
formity is rarely pronounced. In one exceptional compound case 
seen by the author there was a fracture of the shaft of the first 
metatarsal, a little below the middle, and the distal fragment was 
turned completely around on a transverse axis, so that the articular 
end rested against the distal end of the proximal fragment. 

Diagnosis. — There is usually little difficulty in recognizing a frac- 
ture of one or more of these bones. Their dorsal surfaces are 
practically subcutaneous, and if the case is seen early much can 
be learned by direct palpation. If the swelling and traumatic 
reaction are well advanced before the surgeon is called, the parts 
may be exquisitely tender, and under such circumstances it is 
preferable to determine the presence of fracture by the use of the 
X-ray, rather than to administer an anesthetic and establish the 
diagnosis by palpation and manipulation. 

If pressure is made on the ball of the foot (between the toes and 
the ball) and toward the base of the bone (that is, in the direction 
of the axis of the metatarsal) pain may be produced at the seat of 
fracture in the corresponding bone. Pressure should be made in 
this way over the head of each metatarsal. 

Treatment. — The foot should be placed on a plaster sole which is 
moulded so that it properly supports the arch of the foot. This 
splint should extend from the middle of the leg to a point beyond 
the toes. Traumatic reaction should be controlled by the inter- 
mittent application of the ice cap, and by keeping the foot in the 
elevated position. If deformity exists it should be corrected be- 
fore the plaster sole is applied. 

Operative Treatment. — Compound cases are common and the 
operative treatment in these cases is practically the same as that 
given on page 712 under ''Fractures and Dislocations of the 
Cuboid, Scaphoid and Cuneiforms." Open treatment to correct 
deformity in simple cases is practically never indicated. 

After-Treatment. — Union takes place in simple cases in three to 
four weeks. Weight bearing should be only gradually resumed, 
since ventral bowing may occur if the first metatarsal alone or 
more than one of the other metatarsals has been broken, and the 



FRACTURES OF THE METATARSALS 719 

patient walks too soon. Hot applications, passive motion and mas- 
sage will hasten the time w^hen the patient will be able to enjoy 
free use of the foot. 

Prognosis. — The severity of these lesions varies greatly, and ac- 
cordingly the outlook will depend on the amount of damage done. 
Simple, uncomplicated injuries should be followed by complete 
restoration of function. Severe crushing injuries may require im- 
mediate amputation. 



CHAPTER LYI, 

FRACTURES AND LUXATIONS OF THE PHALANGES. 

Surgical Anatomy. — The structure of the bones of the toes is 
similar to that found in the fingers. The toes may be broken in 
crushes of the foot, and resemble the condition as occurring in the 
metatarsals. The toes are practically alwaj^s broken by direct vio- 
lence. The accident is common among laborers and results from 
heavy objects being dropped on the foot. A not uncommon form 
of injury is one in which the toes are caught in a moving elevator. 
The great toe usually sutiPers most and the crushing of the parts 
is scA^ere when produced in this way. Stubbing of the toes against 
some projecting object, w^hile the patient is barefooted, is fre- 
quently responsible for fracture of one or more of the phalanges, 
especially that of the little toe. Luxations of the toes are rare and 
resemble those seen in the fingers. 

Symptoms. — The amount of disability is almost entirely de- 
pendent on the severity of the causative trauma. In simple frac- 
ture of the little toe the patient is usually able to get about with 
little difficulty although pain may be severe immediately following 
the accident. On the other hand severe crushing injuries, such as 
sustained in the usual elevator accident, completely disable the pa- 
tient. Crepitus, pain and swelling are present. Crepitus may be 
difficult to elicit if the fracture is in the distal phalanx, because of 
the splinting effect of the nail. 

Treatment. — The parts should be immobilized on a plantar splint. 
The displacement is usually moderate and can be corrected without 
difficulty. In fractures of the great toe the patient should be pre- 
vented from bearing weight on the foot until union is solid. In 
fracture of the smaller toes the patient may be allowed about as 
soon as the traumatic reaction has subsided. The great toe is an 
important factor in walking but the lesser toes have little to do 
with the usefulness of the foot. If fibrous union takes place in 
one of the smaller toes there will be no subsequent disturbance in 
function. When the little toe alone is fractured it will usually 

720 



FRACTURES AND LUXATIONS OF PHALANGES 721 

not be necessary to employ a splint in the treatment of the condi- 
tion. If cotton is placed between the little toe and the adjoining 
digit, and the injured toe strapped in position with adhesive, the 
necessary immobilization will have been accomplished. In com- 
pound, crushing injuries the important element is the damage done 
to the soft tissues, and the case must be treated accordingly. Gan- 
grene may develop in one or more of the toes if the crushing has 
been severe, and amputation may be necessary. 

Prognosis. — In simple uncomplicated cases the prognosis is good. 
If the accident results in the loss of the great toe there may be a 
limp, more or less noticeable in the patient's gait. 



PART IV. 
SPECIAL SUBJECTS. 



CHAPTER LVII. 

TERMS AND DEFINITIONS. 

Fracture. — No better definition can be given than the meaning 
of the Latin word {f rang ere, to break) from which the term is de- 
rived. A breaking of bone or cartilage. 

Dislocation or Luxation. — Is a condition in which the articular 
surfaces are completely displaced from each other. These terms 
are often looselj^ used, and in many instances an incomplete dis- 
placement of the articular surfaces is spoken of as a dislocation 
when it should be designated as a subluxation. 

Subluxations are dislocations in which the articular surfaces re- 
main partly in contact with each other. 

Complete and incomplete are terms used to indicate the degree 
of fracture or luxation. In incomplete fractures the line of frac- 
ture only partially separates the fragments. 

Congenital fractures and luxations are conditions which exist at 
birth. In many instances it is difficult to state whether or not the 
lesion was intra-uterine. Congenital fractures and luxations may 
be the result of prenatal disease, defective development or of 
trauma at birth, or of a combination of these causes. 

Spontaneous fractures and dislocations occur as a result of dis- 
ease or paralysis. In some instances, notably fracture of the hip, 
the bone may break under normal strain as a result of the absorp- 
tion and rarefication of bone which takes place in the aged. 

Pathologic fractures are caused by diseases of the bone such as 
osteo-sarcoma, carcinoma, osteo-myelitis, etc. 

Pathologic luxations result from diseases which cause degener- 
ation of the ligaments or alterations of the articular surfaces. 

Recurrent or hahitual luxations are conditions in which the same 
dislocation takes place repeatedly, following incomplete healing of 
the ligaments after the initial lesion. Recurrent luxations are com- 
mon in the shoulder joint following improper treatment of the first 
displacement. 

Diastasis and distraction are terms used to indicate a condition 

725 



726 FRACTURES AND DISLOCATIONS 

in which the joint surfaces are forcibly torn from each other and 
remain separated without overriding- deformity. A good example 
of diastasis is sometimes seen in the lower tibio-fibular articulation 





Fig. 783. Fig. 789. 

Fig. 788. — Example of a simple transverse fracture. 
Fig. 789. — Example of multiple fracture of the shaft. 

when the ligaments are torn and the lower ends of the tibia and 
fibula separated. 

The term compound or open is used when the fracture or lux- 
ation is connected with the outside air by means of a wound. The 
wound may be made by the vulnerant body penetrating to the 



TERMS AND DEFINITIONS 



727 



bone, or the end of the fragment or articnlar surface of the bone 
may penetrate the skin from within. 

The term closed is used in contradistinction to open or com- 
pound. 




Fig. 791. 



Figs. 790 and 791. — Surface form and section of fracture united in deformity. Old 
fractured tibia sawed in the coronal plane. Note how the rough fractured surfaces not 
originally in apposition have been absorbed, filled in and rounded off, as the middle of 
the callus became more dense. _ When union takes place with deformity, as in this case, 
the callus is of necessity heavier and more dense than when good reduction has been 
accomplished. This specimen was obtained from the dissecting room and is probably 
many years old yet the medullary canal has not reopened. _ In fractures of the shafts 
of long bones the medullary canal reopens some years following the injury provided the 
reduction is good. In this case the deformity is pronounced and the medullary canal 
remains occluded by the internal callus. A good example of the reopening of the canal 
is seen in the X-ray plates (Figs. 636 to 639), 



The term simple is used in contradistinction to both compound 
and complicated. 

The term complicated is rather indefinite in its meaning. It is 
used w^hen the fracture is compound or open and is also employed 



728 



FRACTURES AND DISLOCATIONS 



to indicate associated injury to arteries, veins, nerves or muscles. 
It is also used when the fracture is infected. 

A green-stick fracture is one in which the line of fracture re- 
sembles that seen when a green-stick is broken. The bone is bent 




Fig. 792. — Carcinoma of ,the liumerus with spontaneous fracture. 
Fig. 793. — Carcinoma of the humerus with spontaneous fracture. 



and the fracture involves only the convex side of the shaft. Many 
fractures are called green-stick which are in reality of the sub- 
periosteal type. 

Siihperiosteal fracture. — This term is used when the fracture is 



TERMS AND DEFINITIONS 



729 




bone. 



Fig. 794. — Carcinoma of the lower end of tlie femur with extensive destruction 



730 



FRACTURES AND DISLOCATIONS 




Fig. 795. — Syphilitic dactylitis with spontaneous fracture. 




Fig. 796. — Spontaneous fracture following osteosarcoma. 



TERMS AND DEFINITIONS 731 

not accompanied by appreciable tearing of the periosteum or dis- 
placement of the fragments. It occurs in children and is the result 
of bending force applied to the bone. AVhen this type of violence 




Fig. 797. — Osteocarcinoma with spontaneous fracture. Much destruction of bone. 

is applied to a young bone (young bones are tough rather than 
brittle) the convex side of the shaft is under tension strain while 
the concave side is under compression strain. Fracture may 



732 



FRACTURES AND DISLOCATIONS 




TERMS AND DEFINITIONS 



733 




Fig. 7 'J 9 



Fig. 799. — Same case as shown in Fig. 798. Note fracture of femnr 
Fig. 800. — ^Same case. Note fracture of femur. 




mms;:< 




Fig. 801. 



Fig. 802. 



Fig._ 801. — Same case. Note bowing of tibia and point in shaft which is ready to 
break with the slightest strain. 

Fig. 802, — Same case. Same conditioia as seen in tibia of opposite leg in Fig, 801. 



734 FRACTURES AND DISLOCATIONS 

occur on the convex side from tension or on the concave side 
from compression. When the former type of fracture occurs and 
is incomplete we have the typical green-stick fracture. When 
the latter type occurs we have the subperiosteal form of fracture. 
The difference is well illustrated by the manner in which different 
forms of iron break. Wrought iron girders break on the concave 
side from "buckling," while steel girders break on the convex 
side with clean fracture. The more brittle the material the more 
likely the fracture is to begin on the convex side of the column and 
to be complete. The more rapid the bending the greater the proba- 
bility of a complete fracture and of the break beginning on the 
convex side. 

Various terms are used to indicate the nature of the fracture, 
the character of the deformity and the line of the break. Such 
commonly used terms as : comminuted, multiple, transverse, oblique, 
spiral, overriding, angular, depressed, etc., are self-explanatory. 



CHAPTER LVIII. 

THE USE OF THE X-RAY. 

BY H. G. STOVER, M.D. 

After the lapse of some eighteen years since Rontgen's discovery, 
it ought not to be required, in a work upon fractures and disloca- 
tions, to insist upon the absolute necessity for the routine use of this 
indispensable diagnostic means in every instance of possible bone 
or joint injury. 

Yet even in this day, when the benefits of Rontgenology are avail- 
able in so many localities, the use of this agent is far from as 
general as it should be. 

In the early days of the Rontgen ray there was some excuse for 
the surgeon who did not rely upon it : the users of the ray were not 
in possession of efficient apparatus ; exposures were long, and often 
resulted in harm; and, owing to imperfect technique and small 
experience, the information afforded by a Rontgenologic examina- 
tion was in many instances incomplete, and at times misleading. 

These excuses do not hold now; in every center of population 
there are installations capable of giving useful Rontgenograms, and 
men who are competent to make the examinations skillfully and 
without danger to the patients. 

The advantages of the Rontgenologic examination are many and 
vital. 

The Rontgen examination does away with the need for manipu- 
lation of injured parts in the attempt to elicit pain, crepitus and 
preternatural mobility; it not only affords all the information of 
value to be gained from the ordinary methods of examination, but 
it brings forth facts impossible to be elicited in any other way : 
certain fractures Avithout displacement ; certain impacted fractures ; 
certain incomplete fractures; certain fractures, which, by their 
very nature cannot give the usual clinical signs ; it reveals the inter- 
position of small fragments between the ends of fractured bones; 
and avoids the bruising and laceration of tissues which must occur 
in some instances if there be a prolonged manipulative examination, 

735 



736 FRACTURES AND DISLOCATIONS 

It has been argued by some that a surgeon ought not allow his 
manual dexterity to suffer the atrophy of disuse, by relying upon 
the Rontgen ray ; one might as well say that an internist ought not 
use the microscope to look for plasmodia in the blood, but ought 
rather nurse his skill in eliciting subjective and objective clinical 
symptoms upon which to formulate his diagnosis. At the same 
time, it must be insisted that the Rontgen examination is not to 
supplant the clinical methods ; rather must it supplement them. 
The skilled hand of the surgeon has done its wonders through the 
ages; it cannot be neglected now; the practised eye discovers ex- 
ternal signs of internal conditions in a marvelous way as evidenced 
by the photographs in this book. 

The time is coming when failure to make appropriate use of 
Rontgenology, when accessible, will be counted as negligence, and 
this not only in surgery, but in many departments of internal 
medicine. Even the laity are coming now to criticise their attend- 
ants for delay or neglect in this matter. 

After attempted reposition of fracture or dislocation, the Rontgen 
examination affords a means of ascertaining if position is correct 
without disturbing retentive dressings or apparatus, enables one to 
watch the course of healing, and to know the final anatomical result. 

In many of the fractures met with, a clinical diagnosis sufficiently 
accurate for preliminar}^ treatment can be made ; in these cases the 
Rontgen examination should be made after reposition in order to 
check up the clinical diagnosis and to make certain that satisfactory 
reposition has been accomplished. But there are not a few in- 
stances in which the Rontgen examination should be made before 
anything else is done ; in this class are many of the injuries about 
the elbow, hip, and pelvis, and those severe traumata in which there 
is suspicion of grave damage to vital soft tissues, and further injury 
through manipulation might result in gangrene, or other detri- 
mental sequelae. 

As the Rontgen ray produces no sensory impression upon the 
retina, it is necessary to use intermediate means to transform the 
results of its energy into visible records. 

There are three physical factors which render this possible : 

First : all substances absorb the Rontgen ray practically in rela- 
tive amounts corresponding directly to the ratio existing between 
their atomic weights. 

Second : the Rontgen ray causes certain substances to fluoresce. 



THE USE OF THE X-RAY 737 

Third : the Rontgen ra}^ has the power of producing a paralyzing 
effect, or a latent, developable image, upon the chemicals used in 
the sensitive emulsion of photographic plates and certain photo- 
graphic papers. 

If a substance is so placed that it will intercept rays directed 
toward a screen coated with fluorescent material, or a photographic 
plate, the absorption which occurs leaves areas on the screen or 
emulsion, which are not affected ; these areas on the fluorescent 
screen are dark; in the emulsion of the plate no latent image is 
produced ; if the substance under examination is made up of areas 
of various densities, the amount of fluorescence upon the screen or 
of alteration in the silver salt of the emulsion of a plate, in corre- 
sponding areas, varies in an inverse proportion to the densities of 
these areas, or in direct ratio to the amount of rays which these 
areas permit to pass. 

At the present time the fluoroscope is not used in this branch of 
surgical Rontgenology, except for roughly and quickly estimating 
the approximate location of a foreign body, or obtaining some 
general facts regarding a bone injury; the screen image is not so 
rich in detail as is that upon the plate; it can be studied during 
only a short period of time ; it is not a permanent record ; its fre- 
quent use is dangerous to the operator; long or repeated exposure 
may lead to injury of the patient's skin, as for example, when the 
operator, the attending physician, perhaps a consulting surgeon, 
and probably from one to a dozen relatives and friends, must all 
' ' have a look. ' ' On the other hand the sensitive plate gives all the 
details; it can be studied as long or as often as needed and at any 
time ; it is a permanent record of the condition ; it is demonstrable 
evidence that such an examination has been made; in addition to 
this, the accumulation of a large library of plates furnishes rich 
material for scientific study and for the writing of papers. 

The great part of Rontgen diagnosis in medicine and surgery 
must be done by specialists in this line, and indeed before long there 
will be subspecialties in Rontgenology, so great is the field and so 
complicated the technical details of diagnosis-making. Most 
physicians and surgeons will find it impracticable to make their 
own Rontgen examinations. A complete equipment is costly in 
apparatus and space and its maintenance expensive. One's own 
patients will not contribute as liberally to this for these examina- 
tions as they will do when referred to a specialist for the purpose. 



738 



FRACTURES AND DISLOCATIONS 



and men cannot give time from a busy practice to carry out the 
work. The physician who does not have reasonably ready access 
to a competent Rontgenologist may well, however, prepare and equip 
himself to examine fractures and dislocations by this method. He 
will not need the powerful generating machines, the complicated 
auxiliary apparatus or the costly tubes necessary for instantaneous 
Rontgenography of the lungs and stomach. Yet let not such an 




Fig. 803. — The Rose portable coil. 



one imagine that he is taking up a simple problem ! For this man 
the author would ad^dse the Rose Portable Coil (Fig. 803), It may 
be used on either direct or alternating current; it is of the compact 
' ' suit-case ' ' type and can be carried in the hand for short distances 
without overfatigue, so it may be used either in the office or at the 
beside where electric current is available. In Fig. 804 is shown a 
larger apparatus of the same type. It is more powerful but is 



THE USE OF THE X-RAY 



739 



more weighty and heavier fuses must be placed in house circuits in 
which it is used. Another box for carrying the Crooke's tube and 
the plate-hokiers is a convenience. The apparatus requires a special 
type of Crooke's tube, calculated to suppress inverse current (Fig. 

805). 




Fig. 804. — This apparatus is similar to that shown in preceding figure. It is. liow- 
ever, more powerful and more weighty. Heavier fuses must be placed in the house 
circuits on which it is used. 



The Cramer, the Forbes, or the "Agfa" X-ray plates will be 
found quite satisfactory, permitting of some latitude in exposure 
time. 

These plates are to be enclosed in the black and yellow envelopes, 



740 



FRACTURES AND DISLOCATIONS 



opaque to ordinary actinic light, which may be procured from the 
plate makers. Always put the plate in the black envelope (in the 
dark-room, of course) so that the film of the plate is next to the 
smooth side of the envelope ; then put the black envelope into the 
yellow one so that their smooth and unprinted sides are tog-ether; 




Fi^. 805. — Special type of Crookes tube, calculated to suppress inverse current. 

this is important, as in this way one is always certain as to which 
side of the package carries the film side of the plate. If Rontgeno- 
grams are made with the film side of the plate down in some 
examinations and up in others, when using envelopes, there might 
be no way of knowing, in a subsequent stud}' of the plate, whether 




I'ig. 806. — Metallic; numbers for marking X-ray plates. 

the right or left side of the body had been examined, a point which 
it is quite necessary to know when making reports to insurance 
companies, or when the physician is called to the witness stand. It 
is a very good plan to mark the plates, at the time of making the 
exposure, by means of leaden letters "L" and "R." 



THE USE OF THE X-RAY 741 

For several reasons it is quite important that plates be carefully 
so marked that their future identification is always positive. Metal- 
lic numbers (Fig. 806) may be placed on the plate at the time of 
the exposure, thus obtaining a Rontgenogram of the number as a 
part of the image produced; if this is not practicable the number 
of the plate or the patient's name, should be written upon the film 
side of the plate, in the dark-room, wdth a lead pencil, immediately 
before developing it. 

When the Rontgenogram has been made, the following points 
should be noted upon the envelope, for a record : name of patient ; 
address; occupation; if a minor or a dependent, the name and 
address of the financially responsible party ; the date ; the part 
examined; the nature of the view^ — whether antero-posterior, 
postero-anterior, lateral, etc. ; the condition suspected; the diagno- 
sis ; and other facts may be added if desired, such as, history of the 
injury; description of the dressings applied, etc. 

The plates should be filed aw^ay in a safe place in such a way 
that they will be readily accessible for future reference. Filing 
may be done according to number, or in groups of "parts of 
body," or in groups of "lesions found." An index of such a 
nature that plates may be found easily, should also be kept. 

Do not permit patients or others to carry away your plates ; you 
may want them badly yourself some day. The plate is the most 
important part of your record of your work; it may be needed for 
study of the progress of a case ; it may be needed in court ; in time 
your plates form a valuable library as already stated. 

The author does not permit his plates to be introduced in evi- 
dence as "exhibits" in medico-legal cases; when the author is on 
the stand and is asked to show his plates to the jury, he says to the 
Judge, "May it please your Honor, these plates are a part of my 
professional records; they are necessary to me as such, and as 
material for scientific study ; I therefore do not desire to introduce 
them into evidence as exhibits, but simply to use them as diagrams, 
by means of which to demonstrate the opinion I am here to 
give." This has always been allowed without question by the 
Court. 

Prints, if they are of such a nature that they will show^ the con- 
ditions according to the opinion of the expert, may be introduced 
as exhibits. Personally the author does not think plates or prints 
ought to be made exhibits in evidence. The Rontgenologist is not 



742 



FRACTURES AND DISLOCATIONS 



in court as a photographer, but as a medico-legal expert whose 
opinion is being given. 

The Rontgen ray is a form of energy proceeding in divergent 
lines from its source. This most important fact must be borne in 
mind when posing patients for examination and when reading the 
negatives obtained. On account of this divergence, we have this 
fact to remember : other things being equal, the quantity of Rontgen 
ray falling upon a surface varies inversely with the square of the 
distance of that surface from the source of energy. Suppose a 
surface (Fig. 807) one foot square exposed to the Rontgen ray at a 
distance of one foot from the target of the tube ; let A be the target 
of the tube; let BCDE be the surface exposed; then this square 





Fig. 807. 



Fig. 808. 



foot of surface is receiving a pyramid of rays included in AB, AC, 
AD, AE ; now extend these lines until they reach a plane at a dis- 
tance of two feet from the target (Fig. 807), and they include the 
surface FGHJ, which will be found to contain four square feet; 
therefore the same pyramid of rays at one foot distance covering 
one square foot of surface, at two feet distance covers four square 
feet. 

Another important factor in posing is now to be brought out 
(Fig. 808). Suppose the target of the tube at A, the object to be 
examined X-Y. If a plate is placed at B-C, the image of X-Y is 
somewhat but very little magnified on B-C ; but if now the plate is 
moved to B^-C\ leaving the object X-Y close to the target as before, 



THE USE OP THE X-RAY 



743 



the shadow of X-Y takes on the length B'-C\ a very great distortion. 

If, however (Fig. 809), both plate and object examined are 

moved far from the target, the image of X-Y on plate B-C is 




Fig. 809 



much more nearly the actual size of the object than when both were 
close to the target. 

Further, pose, for our "object," a sphere containing in its center 
a smaller and denser spherical mass, so that the plate and the object 




are near each other, but at a good distance from the target A, yet in 
such a position that the line PA (representing the principal axis of 
rays, those falling perpendicularly upon the plate) pass far from 



744 FRACTURES AND DISLOCATIONS 

the center of the object, as in Fig. 810. The Rontgenogram result- 
ing from this pose, shown in Fig. 811, gives a distorted image of the 
object. The outline of the image is far from being circular in form, 
and the image of the smaller sphere is not at the center of the image 
of the large sphere. 

. From these facts we may deduce a general rule for so posing as 
to avoid distortion: 

The object and the plate should be as close together as possible; 
they should be as far as possible from the target (consistent with 
securing sufficient quantity of ray) ; the rays falling from the target 
perpendicularly upon the plate should pass through the center of 
the object. 

A distance of from eighteen to twenty-four inches between tube 
and plate is usually used. 

Now this cannot be an absolute rule ; it must be infringed upon in 
respect of the relation of the principal axis of rays and the center 
of the object, at times. For example: a patient with a suspected 
fracture of the neck of the femur, exhibiting considerable eversion 
of the loAver extremity ; as the patient lies on his back, the plane of 
the neck of the femur is not parallel with the surface of the plate 
placed underneath ; rays passed through the neck of the femur and 
falling perpendicularly upon the plate, would give a foreshortened 
image of the neck, largely covered by the superimposed shadow of 
the greater trochanter; therefore the exposure to show a fracture 
of the neck of the femur in such a case as this must be made 
with the target of the tube outside of a perpendicular from the plate 
passing up through the neck ; this oblique direction of the raj^s will 
show the full length of the neck. 

In making a Rontgenogram of the ankle-joint, antero-posterior 
view, with the toe pointing directly upward, perpendicularly to the 
plate beneath, the target should be placed a little to the outside of 
the perpendicular, in order not to superimpose the shadows of the 
lower ends of the tibia and fibula. 

The rays proceeding from different Crookes tubes are not always 
the same in quality ; the" quality of ray from any given tube will 
vary from time to time. There is a variation in quantity depend- 
ing upon the exciting current ; beside this, there are all degrees of 
variation in penetrating power, dependent largely, apparently, upon 
the nature of the vacuum in the tube, other things being equal. 



THE USE OF THE X-RAY 745 

In general we speak of the rays as being "soft," ''medium," or 
"hard," and we use the same terms in describing the tubes. 

The soft ray comes from a "soft" tube, of low (comparative) 
vacuum; these rays are emitted in large quantity, have a consider- 
able chemical action, but are of low penetrating power. These are 
the rays which quickly lead to dermatitis if permitted to act too long 
on the tissues. They produce very contrasty Rontgenograms of 
thin parts. 

It is worse than useless to attempt the production of a Rontgeno- 
gram of a thick part with a soft tube by unduly prolonging the 
exposure ; this simpl}" over-doses the tissues with rays which are all 
absorbed, and the only result will be a " burn. ' ' 

The hard rays come from a "hard" tube, one of high vacuum; 
they are emitted in relatively less quantity, have less chemical 
action, but are very penetrating. 

The medium rays come in large quantity from a tube of (com- 
parative) medium vacuum, and are best for general purposes, giv- 
ing good bone-structure and contrast between bone and soft tissue. 
For bone work in very thick parts a harder ray is better. If too 
hard a tube is used, the extremely penetrating rays being so little 
absorbed by the bony tissue, give a flat negative without contrast 
between bone and soft tissue. 

The user of the Rontgen ray should be very careful to protect 
himself from its deleterious effects. This is a matter of the utmost 
gravity ; repeated exposures are bound to produce the specific results 
upon the tissues ; the Rontgen ray is not a plaything. A serious 
dermatitis results invariably in carcinoma with a strong metastatic 
tendency, and the death roll of Rontgenologists, with several yet 
living whose names will soon be added to it, is already too large. 

In addition to the fact of the danger to life from incautious ex- 
posure, is the fact that the ray affects the reproductive organs in 
such a way as to produce sterility (not impotentia). 

Fluoroscopes are now provided with lead glass for protection, and 
opaque gloves, aprons, gowns, etc., may be procured. There are 
shields of heavy lead glass, white oxide of lead, or rubber compound 
which may be placed directly about the tube, and which are quite 
opaque to the ray. 

In estimating the time of exposure for different parts, one should 
consider: the thickness or density of the part; the distance of the 



746 



FRACTURES AND DISLOCATIONS 



tube ; the penetrating power, or liardness of the ray used ; the amount 
of current passing through the tube; the kind of plate used (some 
are much more rapid than others). The use of an intensifjdng 



Fig. 812. — Radio-chronometer. 



screen cuts down the time from one-fifth to one-tenth, but it also cuts 
down in the same proportion the allowance of latitude for error in 
calculation. 

There are scales for measuring the penetrating power of the 




Fig. 813. — The Bauer qualimeter. 

ray; the best of these is the Benoist radio-chronometer (Fig. 812) ; 
with this, when viewed through the fluoroscope, or its image studied 
upon the plate, a comparison is made of the color produced by rays 



THE USE OF THE X-RAY 



747 



which have passed through pieces of aluminum of different thick- 
ness, with that produced b}^ raj^s which have passed through a piece 
of silver of a standard thickness. 

The hardness of the rays may be measured by means of the Bauer 
Qualimeter, a sort of electro-static torsion balance (Fig. 813). 

A special milliamperemeter is used for measuring the quantity 
of high voltage current passing through the tube. 

Thus quite an accurate technique may be built up. Experience 
soon teaches how to estimate the values of the various factors so that 
the calculation with these becomes automatic with the experienced 
operator, 

AYith small apparatus, such as has been recommended for the 




m 




Fig. 814. — Linear fracture of upper end of tibia. 

amateur Rontgenologist, it is necessary to make rather long ex- 
posures in order to produce good plates of the thicker parts; thus 
the quiet of the part may be disturbed by respiratory movements, 
or muscular twitchings may occur, or nervous patients may find it 
impossible to remain quiet. The exposure time may be shortened b}^ 
the use of intensifying screens as has already been said. Such a 
screen consists usually of a sheet of cardboard upon which has been 
laid a smooth coat of some substance which fluoresces when exposed 
to the Rontgen ray. This fluorescent light is much more active 
actinically than is the Rontgen ray itself. In use, the chemical 
side of the screen is placed in very perfectly intimate contact with 
the film of the plate (a special plate-holder is necessary) ; this 



748 



FRACTURES AND DISLOCATIONS 



plate-holder is placed under the part to be examined, preferably 
with the glass side of the plate toward the patient and tube; the 
exposure is then made, and very much shorter than when the screen 
is not used; in the dark room the holder is opened, the screen 
quickly remaved and placed in its container and the plate developed. 
Unless a fine screen is used and great care taken that the exposure 




Pis. 815 



Fig. 81( 



815. — Antero-posrerior view of fracture of the radius. 
816. — Lateral view of same case. 



is neither too long nor too short by a very small margin, the result 
will not be satisfactory ; if there is even a slight overexposure the 
image will be "grainy" and the lines of bone-structure will not be 
sharp and clear. The technical difficulties are multiplied by the 
screen, but its use will be of value when examining thick parts with 
small apparatus. 

The Rontgenogram (Fig, 814) produced is not a photograph; it 



THE USE OF THE X-RAY 749 

is a record of the combined, superimposed images of the various 
densities contained in an almost infinite number of planes in the 
object examined, through which the ray has passed. 





Fig. 818. 

Fig. 817. — Fracture of the femoral shaft which cannot be detected because the ravs 
do not pass through the plane of the fracture. 

Fig. 818. — Another plate of the same case. No evidence of fracture. 

A single view of a fractured bone is seldom or never sufficient for 
the diagnosis; exposures should be made from at least two points 
of view, generally at right angles to each other, and sometimes more 



750 



FRACTURES AND DISLOCATIONS 



are necessary to bring ont obscure points, since the Roentgenogram 
is in a way a silhouette or shadow image. 





Fig. 819. 



Fig. 820. 



Fig. 819. — Another plate of. the case shoT\^n in Figs. 817 and 818. The outlines 
seen in the middle of the shaft might lead one to suspect fracture but are hardly sufficient 
to establish a diagnosis. 

Fig. 820. — Another view of the same case showing the fracture quite distinctly. 
This plate and Figs. 817. 818 and 819 demonstrate the possibility of overlooking a 
fracture if the case is examined only in one plane. 

Fig. 815 shows an antero-posterior view of an old fracture of the 
radius ; the lateral view shown in Fig. 816 demonstrates very strik- 
ingly the need of more than one view. 



THE USE OF THE X-RAY 751 

Figs. 817, 818, 819 and 820 are all views of the same femur (child) 
taken from ditferent viewpoints. 

In certain parts of the body (the shoulder, for example) it is 
impossible to obtain two views at right angles to each other ; here the 
stereoscopic method is of special importance. In this method two 
views are made from slightly different viewpoints, but bearing a 
mathematical relation to each other. For the first view the target 
of the tube is placed one and one-quarter inches to one side of a 
perpendicular from the plate passing through the center of the 
object ; the second plate is made after moving the target an equal 






:M 



Fig. 821. Fig. 822. 

Figs. 821 and 822. — Stereoscopic Rontgenogram of a low subcoracoid dislocation of 
the shoulder. 

distance to the other side of the perpendicular. Stereoscopic plates 
are observed by means of a plane prism stereoscope (not the usual 
parlor instrument), and a perspective view results, enabling one to 
get all the relations between the parts of the image (Figs. 821 and 
822, subcoracoid dislocation of humerus). This stereoscopic view 
may be studied by means of a trick of visual accommodation if one 
has not a stereoscope handy ; direct the gaze to a point midway be- 
tween the two plates, then focus upon an imaginary object some dis- 
tance beyond ; this will cause the appearance of three images ; study 
the middle one, disregarding the two outside. 

One should do his own developing, instead of referring it to a 



752 FRACTURES x\ND DISLOCATIONS 

photographer; the photographer may be a better technician at the 
outset, but he is rarely sufficiently acquainted with anatomy and 
pathology so that he will know at what stage of development to 
arrest the process. 

The dark-room must absolutely exclude all daylight or artificial 
light save that from the red lamp. The red light should be tested 
by exposing small plates to it and developing them, in order to make 
sure it is a "safe light." If possible it is w^ell to begin the develop- 
ment of plate in total darkness. Put the plate, film up, in the tray 
and quickly swirl the developer over it, then continuously rock the 
tray, slowly ; hold the plate up to the red light after a time, and from 
time to time, in order to observe the progress of- development, but do 
not do this too often, no matter how "safe" the light is. Develop 
until by reflected red light the back of the plate shows some dark- 
ening, or until the image seen by red light transmitted through the 
plate, begins to fade. 

A good developer is that known as the Cole developer, used by 
Dr. L. Gregory Cole of New York : 

Distilled water 32 ounces 

Metol 40 grains 

Hydroquinone . 6 drams 

Sodium Sulphite (dry) 2 ounces 

Sodium Carbonate (dry) 2 ounces 

Potass. Bromide 40 to 60 grains 

A fault of a good many developers recommended for Rontgen 
work is that they do not contain enough bromide. 

The temperature of the developer should not be above sixty-five 
degrees Fahrenheit. After development, rinse the plate carefully 
for a real minute in running water, put it into one or another of 
the hyposulphite of soda fixing solutions in order to dissolve out the 
unexposed silver salt from the emulsion ; after about twenty minutes, 
or at least ten minutes after the foggy white color has gone from 
the back of the plate, put it in running water for one hour; then 
take out and set on edge to dry in a room of even temperature, 
where dust will not fall upon the soft emulsion. 

Be cleanly in the dark-room. Have trays for each special pur- 
pose, use them for no other, and keep them clean. Wear thin 
rubber gloves when developing ; metol is very poisonous to the skin 
of some people. Rinse the hands carefully every time they have 



THE USE OF THE X-RAY 753 

been near a solution. If a very little hypo is carried into your 
developer you will find your plates displaying some very peculiar 
appearances. 

Plates which are not quite perfect in certain respects may be 
improved by intensification or reduction, as indicated by the quality 
of the density, but really in order to obtain a correct plate the 
exposure must have been very nearly correct in the first place ; after- 
manipulations will not make a good plate out of a bad one. 

In studying plates, put them in a window against a clear sky, 
north light preferred. A box fronted with ground glass and con- 
taining electric lamps is a convenience as it may be used at any time. 

]Make plenty of experimental plates of normal parts in order to 
have a standard. It is well, in injury cases, to examine the corre- 
sponding normal part until one becomes familiar with normal 
Rontgenologic anatomy, and has a collection of normal plates. 

There are no "high lights" in Rontgenograms ; these are impor- 
tant in camera photography ; the corresponding condition in a Ront- 
genogram is the black part of the plate outside the field of the 
image ; in Rontgenography we are dealing with what photographers 
call "shadow detail." 

In studying plates, look out for the appearances (artefacts) 
caused by air bubbles adhering to the plate during development, 
finger marks, scratches, light-struck spots due to holes in the 
envelopes, and chemical stain and fog. 

Look out for confusing lines where the shadows of two or more 
bones are superimposed. 

Do not be deceived by the heavy (white) shadow of a ridge 
for muscular attachment, which at times may appear to be the 
margin of a fracture shadow. 

Remember that epiphyses unite at varying periods in the develop- 
ment of the individual. 

Do not mistake a normal center of ossification of a condyle for a 
displaced fragment of bone. 

Remember that a patient may have more than one fracture. 

Remember that a fracture may be located at some distance from 
the seat of pain. 

Remember that a functionally perfect result may appear very 
far from being an anatomically perfect result. 

Just because your plates show good apposition in a fracture 
located near a joint, do not be over-optimistic in your prognosis. 



CHAPTER LIX. 

THE OPEN TREATMENT OF FRxVCTURES. 

The use of the X-ray and operative treatment have, of recent 
years, greatly improved the results in certain fractures and disloca- 
tions. Open treatment is particularly adapted to the correction of 
deformity in instances in which simpler methods cannot accomplish 
reduction or fail in preventing subsequent displacement during the 
after-treatment. Cases in which operation is performed may be 
divided into two groups: the first includes cases in which this 
method has been chosen soon after the injury because of the im- 
proved results which it ma}^ offer; the second includes cases which 
are operated upon as a last resort after non-operative methods have 
been tried and proven unsuccessful, or in Avhich operation was 
demanded because the condition was compound from the first. The 
results of these two groups of cases are quite different and should 
not be confounded when deliberating upon the advantages of opera- 
tive treatment. Consideration at this time is only given to cases in 
which operation is performed as an initial measure because it offers 
better results than non-operative procedures. Operation done in 
compound fractures will be taken up under the headings of ' ' Treat- 
ment of Compound Fractures and Dislocations," page 789. 

All forms of treatment give a higher proportion of functionally 
perfect results in children, and hence the difference between opera- 
tive and non-operative results is less marked before puberty. AVith 
advancing years the proportion of cases in which a better result can 
be obtained by operation increases. Mechanical means for the 
direct or internal fixation of the fragments have been known and 
employed for many years, but it is only recently" that improved 
technique, both as to appliance and asepsis, have demonstrated the 
real value of the operative method. AYire, nails, screws, pegs, 
clamps, ferrules, and absorbable suture materials, have all been 
used, and even now have their appropriate places. But the develop- 
ment of the Lane plate has proven, undoubtedly, the greatest stride 
in the open treatment of fractures. It is a well known fact that 

754 



THE OPEN TREATMENT OF FRACTURES 755 

perfect anatomic reduction is not always essential to the complete 
restoration of function, yet the more cases in which absolutely exact 
reduction is obtained, the greater will be the decrease in the per- 
centage of cases showing loss of function. AVe should, therefore, 
endeavor in each and every case to secure as accurate an anatomic 
result as is possible. Proper operative treatment not only accom- 
plishes more perfect apposition and fixation of the fragments but 
shortens the period of disability, gives better functional results and 
lessens the suffering of the patient. Prohahly the best time for 
operation is fro))i seven to ten days following the accident. This 
allows the tissues to recover from the initial shock and gives time 
for the development of local resistance. In operating on simple 
fractures the surgeon should fully appreciate that he is rendering 
the condition compound, and that infection following open treat- 
ment is often productive of much worse results than would be the 
case if surgical measures had not been instituted. For this reason 
the most strictly aseptic surroundings are demanded and the oper- 
ator should be skilled in this particular branch of surgery. Those 
unaccustomed to bone work should not attempt these cases. The 
surgeon should possess a mechanical sense peculiar to this particular 
type of work, and an appreciation of the relative strengths of the 
materials operated upon and employed. This mechanical sense, 
referred to, is easier to illustrate than to define. For example : if 
we observe an experienced mechanic at work, we never see him 
tighten a nut until the threads strip or the shaft of the bolt twists in 
two, and yet he tightens nuts of all sizes and threads, each one 
requiring a different degree of force to properly seat it. In like 
manner the expert cabinet maker saws and shapes his wood to fit 
the desired places and yet a nail is never driven without due consid- 
eration for the strength and nature of the material through which 
it passes and the function which it is to perform, nor is a screw 
driven home so that the last turn strips the thread, breaks the shaft 
or causes the w^ood to split. On the other hand, if we watch the 
apprentice learning his trade, the lack of mechanical sense is ap- 
parent in the frequency with which he spoils materials and ruins 
his tools. 

Any one who has seen the last screw of a Lane plate split the 
shaft of a bone, or a bone graft broken just as it is being brought 
into position will appreciate the value of this mechanical sense and 
see what can be learned by the surgeon from the artisan. One 



756 FRACTURES AND DISLOCATIONS 

desirous of increasing his proficiency in this particular branch of 
surgery should obtain fresh bones from the butcher and then with 
chisel, saw, nail and screw determine to his own practical satisfac- 
tion the relative strength of bone, and just what it will, and will not 
stand. Later on fresh specimens from the dissecting room should be 
procured and the same experiments conducted. In addition the 
various types of fixation may be tried out on different portions of 
the bone and the security of the fixation tested. The difference 
between cancellous and compact tissue may be appreciated in this 
way and in no other, outside the operating room. When this 
experience has been gained further obstacles to progress may be 
minimized by assisting or observing some surgeon of experience 
in bone work, until a satisfactory technique is obtained. 

The question of when, and when not to operate in a given case 
depends upon the general condition of the patient and the degree of 
reduction which is possible by non-operative methods. Diseased 
states, such as diabetes, erysipelas, advanced nephritis, etc., offer 
contraindications to operation, in the open treatment of fractures, 
the same as they do in other fields of surgery. If the general 
health of the patient allows of an operation, the question then 
arises: "Can an equally good result be obtained by the non- 
operative method as is possible with open treatment ? ' ' and secondl}^, 
* ' Are the proper surgical surroundings and skill available ? ' ' 

In conclusion, then, we might state that with the proper health of 
the patient and available surgical facilities, all cases of fracture 
should be operated, in which an equally good result cannot other- 
wise be expected. 

The site of the operation should be carefully shaved, and painted 
with a three and a half percent solution of iodine (half strength tr. 
iodi) the day preceding the operation. The parts are then covered 
with sterile dressings until the time of operation. The parts are 
again painted with tincture of iodine (five percent) before the 
incision is made. As soon as the skin is divided the cutaneous edges 
should be covered with gauze or towels which are secured in position 
by small tenaculse, thus preventing infection of the deeper struc- 
tures from the cut edges of the skin. Rubber gloves are demanded, 
the hands should be kept out of the w^ound, as far as possible, and 
instruments having come in contact with the gloves should not enter 
the wound. In other words, the most strict aseptic precautions 
should be observed in every detail, gloves should be worn and then, 



THE OPEN TREATMENT OF FRACTURES 757 

while operating, the surgeon should consider his gloved hands 
capable of infecting the wound. The danger in this particular work 
lies largely in the fact that a glove may be torn by one of the serrated 
fragments while attempting reduction, and when this occurs the 
pent-up perspiration from the hand is poured out into the wound. 
A pin-hole in the glove may cause leakage onto the field of operation 
during the entire procedure. 

The details of the operation and the exact form of internal fixa- 
tion which will best meet the requirements of the case in hand are 
often only determined after the bone has been exposed. The exact 
nature of the fracture, with the fragments exposed, frequently 
appears difterent from the conditions anticipated, even though care- 
ful examination has been previously made and the X-ray employed. 
The surgeon should, therefore, have a number of appliances ready 
that he may choose from among them to more perfectly meet the 
requirements of the conditions encountered. If an internal fixation 
appliance is employed it should secure the fragments as solidly as 
may be, even to the extent of sustaining the weight of the extremity. 
In the subsequent treatment, however, splints should be employed in 
such a manner as to relieve the internal fixation appliance from 
as much strain as possible. In other words, internal fixation should 
never be called upon to do the work of splints or other forms of 
external fixation. The fact that internal fixation is so often used 
in the open treatment of fractures does not necessarily indicate that 
the objects of operation may not sometimes be attained without its 
employment. In some instances accurate engagement of the ser- 
rated ends of the fragments during operation, will be sufficient to 
prevent lateral or overriding deformity, and the proper application 
of appropriate splints may be relied upon to prevent angular dis- 
placement. Reduction of deformity and fixation are thus obtained 
by operation, but without the use of any type of internal or direct 
fixation. 

It is essential that the anatomy of the parts operated upon be 
understood so that important structures, such as nerves and vessels, 
may be avoided and the displacing action of the muscles attached to 
the fragments may be appreciated. The internal structure of the 
bone should be understood as well as its surface form, since so much 
depends on the nature of the portion of the bone operated. 

Irrigation of the wound, just before closure, with a gallon or so of 
hot sterile physiological salt solution will promote hemostasis and 



758 



FRACTURES AND DISLOCATIONS 



tend to remove any infection which might have gained entrance 
during the operation. The use of the so-called antiseptic solutions 
within the wound are not only useless, but tend to damage the 
tissues. When possible a running suture of catgut should approxi- 
mate the muscles before the skin is closed. Deep through and 
through sutures are most objectionable. The large majority of 
operations done on fractures pass through heavy muscular tissue 
which is highly vascular. Extravasation of blood into the wound 
is almost sure to follow, even though hemostasis seems perfect at 
the time of closure. Living blood within the vessels possesses 
distinct bactericidal activity, but when extravasated this quality 
soon disappears, the result being that collections of dead blood 
within a wound act as most excellent culture media, at body tem- 
perature, thus favoring subsequent suppuration. It is evident, 
therefore, that fluids forming within the wound following closure 
should be allowed to escape at the earliest possible moment. If a 
few strands of silkworm-gut be so placed within the wound that 
they act as drains, this most important requisite will have been ful- 
filled. The field of operation should be inspected within twenty- 
four or forty-eight hours and gentle pressure exerted in such a 
manner that any fluids which may have collected in the meantime 
will be expressed. 



'VvVyV- 




Methods of using Avire in tlie internal fixation of fractures. 



The Use of Wire has been largely supplanted by the Lane plate, 
though it still retains its place of preference in certain fractures, 
notably those of the olecranon and patella, and in some cases of 
fractures in the extremities of the long bones. The different ways 
in which wire may be used are shown in the accompanying plates 
(Fig. 823). In fractures near the expanded extremities of the 
long bones a single loop of wire properly placed may be sufficient 
to prevent displacement (see Fig. 825). In wiring the shafts of 



THE OPEN TREATMENT OF FRACTURES 



759 



the long bones it is almost essential that two points of fixation 
be employed to secure proper leverage (see Fig. 638). The 
circular wire has the advantage of not entering the medullary 
cavity, and of not requiring the destruction of bone tissue by 
drilling. In most instances the firmest hold is obtained by having 
the wire pass perpendicularly through the plane of fracture 
whether spiral, oblique or transverse. If the fracture approaches 
the transverse type or the serrations are coarse enough to permit 
of firm engagement a single loop of wire may be sufficient to 
prevent lateral displacement, angular deformity being prevented 
by the proper use of splints. 




Fig. 825. 



Figs. 824 and 82 5. — An example of how, a single loop of wire can be made to hold 
the end of a bone in ijosition. 



The essentials in the use of wire are firstly, that the material 
be heavy enough to withstand the strain to which it is subjected, 
and secondly, that it be firmly placed and secure proper leverage 
on the fragments. These points are best appreciated by referring 
to the accompanying diagrams. Heavy wire is as well tolerated 
by the tissues as if the material used were light and inadequate. 
Virgin silver wire has for years been considered the best, but 
recently bronze-aluminum wire has been preferred by many, be- 
cause of its greater torsion strength. 

Nails, Pegs, Screws and Staples have all been used to secure the 
fragments in position, but at the present time the development of 



760 



FRACTURES AND DISLOCATIONS 



more perfect appliances has rendered their use more limited. They 
are only now employed for the purpose of securing a small, dis- 
placed fragment such as a fractured condyle, tubercle or tuber- 




Fig. 826. — Instruments which have been found of considerable service in operating 
on fractures. On the left is shown a lion-jawed bone forceps with ratchet in the handle. 
By means of this instrument it is often possible to hold the fragments in reduction 
while applying internal fixation apparatus. The instruments to the right are ordinary 
retractors with the handle ends shaped and drilled so that they may be used in passing 
wire about the shafts of long bones. 

osity. A good example of the appropriate use of a nail is shown 
in Fig. 219. In this case the external condyle of the humerus was 




broken off and so displaced that the elbow would have remained 
useless if operation had not been performed. The nail has been 
driven at right angles to the displacing pull of the muscles attached 



THE OPEN TREATMENT OF FRACTURES 



761 



to the fragment, and in this position securely holds the condyle 
against the recurrence of deformity. In the use of nails the hole 
drilled in the bone should be only a trifle smaller than the size of 
the nail to be used, otherwise the bone may be split when the nail 
is driven home. The same holds true in the use of screws, pegs 
and staples. 

Screws and nails have been used with some success in the treat- 
ment of fractures of the femoral neck, the nail or screw being 





Fiff. 828. — Bone forceps. 



Fig. 829. — Bone forceps. 



driven through the great trochanter to enter the neck parallel to 
its long axis. The reason that success has not been more constant 
in operating on this portion of the femur is because of the soft, 
cancellous tissue of which the internal structure of the upper end 
of the femur is composed. Screws, nails and pegs depend for 
their hold mainly on compact tissue, and in regions of the skeleton 
in which cancellated structure predominates, little reliance can be 
placed upon them if the displacing action is considerable. Thus 
when a nail is driven into the extremity of one of the long bones it 



762 



FRACTURES AND DISLOCATIONS 



will usually be found possible to tear it out Avith the fingers ; but 
if the shaft is selected as the site of the experiment the nail will 
be found as solidly seated as if driven into wood. This difference 
is entirely dependent upon the disposition of the compact tissue, 
and it is evident, therefore, that before a surgeon operates on a 
given region he should be acquainted with the internal structure 
as well as the surface form of the portion of the bone fractured. If 
a nail or screw once ogives in cancellous tissue the securitv of fixa- 




Fig. 830. — Gerster's turn-buckles for reducing difficult fractures, especially of the 
long, large bones such as the femur and humerus. They may be used to advantage in 
some cases though it is seldom that proper angulation of the fragments and manipulation 
fail in accomplishing reduction in the open method. Great force can be exerted by this 
mechanism and it should not be used without due regard for the damage it may inflict. 



tion is lost, but on the other hand a loop of wire never releases the 
fragments until entirely torn out even though some displacement 
may occur. Screws, like nails, depend on the compact tissue for 
their hold, and it is apparent that their value decreases as the 
epiphyses are approached. The thread of any screw used in bone 
work should continue to the head and the screw itself should be of 
the type used in woodwork. Sherman has devised a screw of the 
machine type with a shaft of uniform thickness throughout. The 
end of the screw is made like a tap so that it cuts its own thread as 



THE OPEN TREATMENT OF FRACTURES 



763 



it sinks into the bone. The principle is good and the screw should 
be efficient, though the author has had no experience with it. 
"When a screw is driven home it should not be too tightly fixed lest 
it strip the threads cut in the bone or cause the subsequent absorp- 
tion of compact tissue through too great stress. Ivory pegs are 
practically unused at the present time. Nails and screws should 
be made of steel and either nickel or silver plated. 




Fig. 831. — Appliance for holding plate in position while screws are being placed, 
ilso holds fracture in reduction. 



The Four-post Clamp. — Numerous modifications of the four-post 
clamp have been devised and used with more or less success though 
they have been almost entirely superseded, in the last few years, by 
the Lane plate. Notable among the variations of the four-post 
clamp is the one devised by Parkhill in which the fragments are 
held in alignment by four long, threaded, steel rods. These rods 
are screwed into drill holes, two on either side of the fracture, and 
held together at their superficial ends by a special locking device 
(see Figs. 832 and 833). The four posts must be in the same plane 
and parallel to each other in order that this particular locking 
device may securely hold them ; it will readily be seen that this 
type of appliance is difficult of application. 

Some other modifications of the four-post clamp do not require 
that all the posts should be parallel, although it is necessary in all 
types that they be in the same plane. Excellent results have been 
secured by using the four-post clamp, and it will be found at the 



764 



FRACTURES AND DISLOCATIONS 



present time the most satisfactory method, next to the Lane plate, 
of securing some forms of fracture. If the mechanics of the clamp 
be studied, and compared with the plate, its inferiority will be 
apparent. In tracing the fixation through the clamp from one 
fragment to the other it will be seen that there are twice as many 
points of possible motion as compared with the plate. Thus a four- 




Fig. 832. — Shows a compound fracture of tibia and fibula. Xote how the upper 

end of both lower fragments project through the skin. The angle at which the leg is 

held shows the flail-like condition. Picture taken a few hours following injury. Case 
seen with Drs. Lyman and Thompson. 




Fig. 833. — Same case as shown in Fig. 832 after reduction and securing of the frag- 
ments by means of Freeman's modification of the four-post clamp. 



post clamp has eight points of possible motion, whereas a four-screw 
plate has only four. In addition to this the four-post clamp is at 
a disadvantage because of the distance of the locking device from 
the bone, which means so much leverage against fixation. Besides 
the mechanical inferiority of the four-post clamp, it will be ob- 
served that four tracts must be left open from the bone to the skin 
when the posts are in position, which can only mean increased risk 



THE OPEN TREATMENT OF FRACTURES 



765 



of infection during the after-treatment. It has been claimed by 
some that the four-post clamp possesses a distinct advantage in 
that no foreign body is ultimately left within the tissues. This 
argument may seem sound theoretically, but practice has proven 



i^^ 




Fig. 834. — Set of Sherman's modification of Lane's 
Pierce & Co. of Philadelphia. Made of Vanadium steel. 



e manufactured by Harvey 



beyond a doubt that certain foreign materials properly placed 
within the tissues are tolerated without the slightest disturbances. 
In the presence of infection all appliances are alike failures, 
whether four-post clamp, plate, nail, screw or wire. It will readily 
be seen, therefore, that the difficulty of application, mechanical in- 



'66 



FRACTURES AXD DISLOCATIONS 



feriority and increased risk of* infection render the four-post clamp 
a much more imperfect appliance than is the Lane plate. 

The Lane Plate. — Lane's method of internal fixation of the frag- 
ments is accomplished by means of cold-rolled steel plates and 
screws as shown in Fig. 83-i. The most rigid asepsis is ohserved 




Fig. 835. — Comparison of the wood screw ordinarily used with, the Lane plate, and 
Sherman's "tap-screw." (After Sherman in Surg., Gynecol. & Ohstet.) 




Screwdriver; special construction to fit tap screws. 
Center point fixes screw and insures vertical and direct 
driving. 

3/e IN, 



Vanadium steel self-tapping (fluted) screws. Three 
flutes are provided at end of each screw, thus combining 
a tap and saew. 

Fig. 836. — (After Sherman in Surg., Gynecol, d- Ohstet.) 



during the entire procedure. As soon as the incision is made, the 
skill edges are protected and other precautions taken to prevent 
infection as previously described on page 756. The incision is 
carried down to the bone and the fragments exposed, brought back 
into alignment and held in apposition by means of a heavy clamp 
of special design, A plate of appropriate size is then placed and 



THE OPEN TREATMENT OF FRACTURES 



767 



held against the bone by the clamp. Holes, slightl}" smaller than 
the screws to be used, are drilled in the bone corresponding in 
position to the openings m the plate. Screws are then driven 



L 




Fig. 837. — Examples of broken Lane plates of the ordinary type. Note the point 
at which the break usually takes place. (After Sherman in Surg., Gynecol. t£- Obstet., 
June, 1912.) 






Fig. 838 



«?.9. 



Fig. 840. 



Fig. 841. 



Fig. 838. — A. P. view of fracture of both bones of leg. 

Fig. 839. — Lateral view of same case. 

Pig. 840. — Same case two years later. 

Fig. 841. — Another view of same case at time Fig. 840 was taken. 



home, securing the plate to the bone which in turn immobilizes the 
fragments. The deep structures are then approximated b}^ catgut 
and the skin incision is closed. Drainage by means of silkworm- 



768 FRACTURES AND DISLOCATIONS 

gut should be established for the first twenty-four or forty-eight 
hours to allow the escape of fluids which may collect within the 
wound. The plate should be accurately shaped to the surface of 
the bone before being screwed into position. It should be so bent 
as to come in contact with the bone throughout its entire extent 
without special stress at any given point. If the plate has been 
securely fixed and the proper aseptic precautions observed through- 
out the operation, it will remain in position indefinitely without 
giving rise to trouble. In the extremities of the long bones the 
plate is not as efficient because of the thinness of the compact tissue 
on which the screws depend for their holds. A simple wire loop, 
properly placed, will often hold the fractured extremity of one of 
the long bones in position more securely than the plate. The Lane 
plate should never cross an epiphyseal cartilage because of the 
possibility of disturbing the subsequent growth of the bone. A 
screw should never be placed closer than one-fourth of an inch 
from the end of a fragment ; the nearer the screws are placed to 
the line of fracture the greater the danger of splitting the bone. 
Plates of various sizes, shapes and weights have been designed by 
Lane to meet the requirements in different portions of the skeleton 
and may be secured from the instrument dealer. 

Absorbable Suture Material is employed and strongly advocated 
by some surgeons for certain fractures in which the displacing 
strain is not pronounced. Excellent results have followed its use 
in many cases, in other instances, however, the nature of the 
material has been responsible for a repetition of the operation 
because of the recurrence of deformity. The nature of the fixation 
required is so different from that to be fulfilled in the approxima- 
tion of soft tissues that one should not employ absorbable material 
lightly and without due consideration for its shortcomings as well 
as its one advantage of being absorbable. It should be remembered 
that the most important time for fixation does not commence until 
eight or ten days after the operation when the bony callus begins 
to form. It is just about this time that absorbable material is 
beginning to lose its strength, and if it releases its hold within the 
first two or three weeks another operation may be necessary. The 
edges of the drill holes may cut the suture material before the 
callus is sufficiently strong to hold the fragments in position. 

The so-called ''ten day" and "twenty day" chromicized catgut 
does not always correspond to the label, in the time which it takes 



THE OPEN TREATMENT OF FRACTURES 



769 



for the material to be removed by absorption. Ten to twenty days 
is more than ample for the processes of healing in soft tissues 
under aseptic conditions. Bone, however, requires a longer period 
in which to unite. If the suture material becomes soft and lax 



Fig. 842. — Tibia from which Lane phitt 
Non-union present in spite of heavy callus 
bone where the screws were placed. 



lias been removed because of infection, 
seen in plate. Note the absorption of 



within a week or two, motion may occur between the fragments and 
delayed or non-union may follow. The surgeon, in the meantime, 
is laboring under the false impression that the fragments were 
securely and permanently fixed at the time of operation. In addi- 



770 FRACTURES AND DISLOCATIONS 

tion it might be stated that chromic gut is not as easy of steriliza- 
tion as are metallic substances, such as wire, and the Lane plate. 
Absorbable suture material is more commonly used in repair of the 
patella and olecranon than in other regions. The purpose is accom- 
plished in either of these two parts hy suturing the torn fasciae 
attached to the fragments rather than by direct suture of the bone. 

In conclusion it might be stated that absorbable suture has the 
advantage of being entirely removed after it has accomplished its 
purpose, but it is so insecure that it had better be discarded, in 
most cases, in favor of some metallic, mechanical material. 

The subject of the open treatment of fractures cannot be con- 
sidered complete without entering into the uses and indications of 
bone transplantation. It is not improbable that many of the estab- 
lished methods in operating on fractures will, in the near future, 
be revised or even discarded when the possibilities and uses of 
bone grafting become better known and further developed. Bone 
transplantation will be taken up in the following chapter. 



CHAPTER LX. 

BONE TRANSPLANTATION. 

One of the most important developments of surgerj^ in recent 
years is the transplantation of bone to fill in deficiencies in the 
skeleton which have resulted from injury or disease. As a sur- 
gical procedure it has become well established in spite of the fact 
that the fundamental underlying principles are as yet by no means 
established. The three theories which have had the greatest fol- 
lowing are those of Axhausen, Macewen and Murphy, and the very 
diversity of these theories points unmistakably to the fact that the 
subject has yet to be explored and the actual facts determined. 
Axhausen maintains that the bone composing the graft invariably 
dies, and is absorbed and replaced by new bone formed from the 
periosteum surrounding the transplant. According to this theory 
the periosteum is all that remains of the original transplant, and 
the success of the operation depends entirely on this membrane. 

Macewen of Glasgow is of the opinion that the graft is repro- 
duced entirely from the osteoblasts within the transplant, and that 
the periosteum has nothing to do with regeneration of bone, but 
acts only as a limiting membrane preventing the osteoblasts from 
penetrating the surrounding tissue. 

Murphy of Chicago states that the graft acts only as a scaffold- 
ing for the production of new bone by the osteogenetic elements 
which pass from the living bone into the transplant at the points 
of contact. In other words, he maintains that the graft is not 
osteogenetic but only osteoconductive, and that therefore the solid 
contacting of the graft with living bone is the important point, 
and not the activity of the periosteum. It is probable that each 
of these theories contains some truth but that no one of them is 
entirely correct. Since the setting forth of these theories much 
experimental work has been done on the subject, and although 
much valuable, practical information has been gained in this way 
yet the ultimate fate of the graft has not been conclusively de- 
termined. From a practical standpoint we are not so much in- 

771 



772 FRACTURES AND DISLOCATIONS 

terested in the theories as we are in knowing the conditions under 
which bone may be successfully transplanted to fill in defects in 
the skeleton. Moreover it is not sufficient to know that under cer- 
tain conditions the operation may be successfully performed but 
we must know^ just which methods will give the highest percentage 
of success, and just what conditions are most likely to interfere 
with the "taking" of the graft. 

In order that we may develop the practical side of the subject 
we must examine into the results obtained in some of the more 
recent experimental work and consider these facts together with 
the theories just referred to and what we know of the embryonic 
development of bone and the repair of fractures. Following frac- 
ture certain tissues, as far as w^e can determine, resume their em- 
bryonic function and produce bone to repair the lesion. In the 
embryo the bone-forming tissues seem to be the periosteum and 
the osteoblast, but whether or not the bone-forming properties of 
the periosteum are inherent to this membrane or are dependent on 
the osteoblast cannot be stated. The bone cell is developed from 
the osteoblast, and in the presence of fracture it is not improbable 
that the bone cell reverts to its embryonic role and produces bone 
provided circulation is not destroyed. It would therefore seem 
that in the repair of a fracture ossification of the soft callus 
emanates from three sources: namely, the periosteum, the endos- 
teum, and from the osteoblasts within the bone near the frac- 
tured surfaces of the fragments. If the bone-forming properties 
of the periosteum and endosteum depend on the osteoblasts then 
the process of ossification resolves itself into one word, viz., osteo- 
blast. A transplant might be considered as an ordinary fragment 
if it were not for the fact that its circulation has been disturbed 
by being removed from its original position. This is a most im- 
portant matter since the life of the bone cell, and hence of the bone 
itself, depends on an adequate circulation. It is an established fact 
that if a section of periosteum be stripped up from the bone and 
transplanted into other tissue (muscle for example), it is capable 
of living and producing bone. Now a normal bone receives its 
circulation from three sources : the periosteum, endosteum and the 
direct ramifications of the nutrient vessel or vessels. In remov- 
ing a graft the branches of the nutrient artery are of course put 
out of function, but if the periosteum, when transplanted, can 
continue to live and reestablish its circulation, it is capable, to a 



BONE TRANSPLANTATION 773 

greater or less extent, of taking care of the attached bone and its 
contained bone cells. In considering the circulation of the graft 
and its periosteum it should be remembered that the function of 
circulation (namely, the supply of oxygen and nutrition and the 
removal cf waste products) can, to some extent be directly ac- 
complished by diffusion, osmosis, dialysis and infiltration within 
the fluids surrounding anci pervading the transplant. A graft 
stripped of its periosteum may live, when transplanted, but the 
chances of its doing so are much less than when the membrane 
is left attached. A periosteum-free transplant is more likely to 
survive if broken up into small pieces, since the fluids thus obtain 
freer access to the bone cells. On the other hand it is well known 
that under favorable circumstances dead bone (sterilized by boil- 
ing and hence killed) has been successfully grafted into defects in 
the skeleton and what would seem still more remarkable inorganic 
materials, such as bars of magnesium, have been placed between 
the fragments and been replaced by strong living bone. The 
chances of transplanted bone living, whether periosteum-covered 
or not, are increased when it is firmly contacted with living bone. 
These facts Avould seem to indicate that Murphy's theory is cor- 
rect, in as far as ossification may take place from osteogenetic ele- 
ments passing from the ends of the fragments into the substance 
of the graft. Magnesium as a graft, however, has had only fair 
success even in regions of greatest vascularity, such as the face. 

It would seem apparent therefore that the periosteum, endosteum 
and the osteoblast (whether situated in the graft or in the frag- 
ments) are each capable of producing bone under favorable cir- 
cumstances and that therefore the technique most favorable to the 
activity of all of these elements, will show the highest percentage 
of success. 

The transplant does not need to be as heavy as the section of 
bone which it is to replace. If the operation is successful and the 
transplant lives, it will increase in diameter until it is capable of 
properly withstanding the full strain to which the bone is normally 
subjected. This increase in size, however, is more or less depend- 
ent on the use of the member after the graft has solidly united. 
In other words, if the member into which the graft is placed is 
kept at rest and not subjected to strain after union of the trans- 
plant, the volume of the graft cannot be expected to increase in 
size to properly take up its function. This means, therefore, that 



774 FRACTURES AND DISLOCATIONS 

after union has taken place the member should be gradually sub- 
jected to increasing strain until the transverse diameter of the 
graft has augmented sufficiently to take up its full function. The 
progress of this growth is best determined by Rontgenograms taken 
at intervals during the after-care of the ease. 

In obtaining a graft only a portion of the diameter of the shaft 
from which it is taken should be removed, since if a section of bone 
including the entire diameter with its periosteum is removed, re- 
pair of the defect with bony tissue cannot be expected. When a 
section of bone is taken from the tibia as shown in Figs. 846, 
847 and 848, the space left in the crest of the shin is entirely 
repaired and filled in with living bone. 

Experience has demonstrated that the procedure is most suc- 
cessful when the graft is taken from the same person. If this is 
not possible the nearest blood relative should be chosen. The pros- 
pect of failure is so great when the graft is taken from one of 
the lower animals that this source has been entirely discarded. 

In order that we may arrive at a practical worldng knowledge 
of the subject we must review the established facts as determined 
by clinical experience and experimental work and apply them ac- 
cording to the principles of modern aseptic surgery, so that in 
a given case the most favorable conditions for the operation may 
be obtained. The most favorable conditions may be summed up 
as follows: 

1. Absolute asepsis. The most rigid asepsis should be observed 
throughout, in exposing the fragments, in obtaining the graft and 
finally in placing it in position to fill in the defect. The graft 
should not come in contact with the gloved hand and the gloved 
hand should not be introduced within the wound if possible to 
avoid it. The subject of asepsis has been considered under the 
heading of "The Open Treatment of Fractures" (Chapter LIX, 
page 758). One should never attempt bone grafting in the pres- 
ence of a discharging sinus or infection of any kind. After the 
sinus or diseased area has healed the operation may be attempted. 

2. The use of an autoplastic periosteum-covered transplant. 

3. The solid contacting of transplant with living bone ; at both 
ends if possible. 

4. It is essential that the transplant be covered with viable soft 
tissue. The thicker the edges of the incision the more soft tissue 
there will be to close over graft. 



BONE TRANSPLANTATION 775 

5. The avoidance, as far as possible, of non-absorbable material 
in fixing' the graft in place. We cannot expect a graft to show as 
nincli resistance as is possessed by a fragment with intact circula- 
tion. 

6. The graft should have a function to perform as previously 
explained. A graft will not develop or may even be absorbed if 
not subjected to some strain after union has taken place. 

7. In obtaining the graft the entire diameter of a shaft should 
not, as a rule, be removed. It interferes with regeneration of the 
defect thus made. 

Indications. — The conditions in which bone grafting is indicated 
are numerous and the future will probably disclose additional uses 
for this procedure. There are three classes of conditions which 
most frequentlj^ call for bone grafting. 

1. To fill in defects in the skeleton. 

2. To produce union between fragments where non-union has 
existed. 

3. For the immobilization of joints and the support diseased 
parts. 

1. The types of skeletal defects are numerous and are classified 
according to the etiologic element. They may be the result of con- 
genital defects, destructive infections, tumor formations and 
trauma. From the standpoint of fractures and dislocations we 
are interested only in bony defects resulting from trauma. In 
severe compound comminuted fractures a large section of a bone, 
more commonly its shaft, may be destroyed and if the parts become 
infected (as they so frequently do, seeing that the injury is sus- 
tained under septic conditions) additional bony tissue may be 
destroyed. The end to be attained in such cases is to clear up 
the infection and obtain healing of the wound. If necrotic bone 
is present it should be removed. (See following chapter on the 
treatment of compound fractures and luxations.) When the parts 
are thoroughly healed an attempt should be made to fill the bony 
defect by bone grafting. The most satisfactory technique will 
usually be found to be the medullary graft or the inlaj^ graft as 
described by Albee. 

2. -Non-union is a condition which in many cases can only be 
corrected by bone grafting. After non-union has existed for some 
time the ends of the fragments become sclerosed and often ebur- 
nated and seem to lose their power of forming bone or at least 



776 FRACTURES AND DISLOCATIONS 

are too dense to allow the penetration of bone-forming elements. 
Under such conditions bone grafting is the only way in which union 
can be obtained. The medullary and inlay grafts are the most 
satisfactors^ methods of transplanting bone to correct non-union. 
The inlay graft seems to be gaining favor over the medullary trans- 
plant in this type of work, although the technic[ue is more difficult 
and requires more special apparatus. 

3. For the purposes of support and arthrodesis bone transplan- 
tation is rarely called for in the treatment of fractures and dis- 
locations. Instability of the knee joint following injury can, as a 
rule, be corrected by repair of the crucial and lateral ligaments. 

Technique. — Bone grafting is by no means a new subject but it 
is only within the last few years that it has been widely employed 
and this is because of the improved results obtained by the more 
recent technique. It is apparent that in the evolution of a subject 
such as this a great variety of methods are evolved and discarded 
before a satisfactory technicjue is finalh^ developed. A detailed 
description of some of the older methods, therefore, would be of in- 
terest from an historical standpoint only. Among those which 
have been most prominent might be mentioned the following: 

1. The transj^lantation of living bone chips to fill in defects. 
As much of the periosteum as possible should be left attached to 
each chip. This method is deficient in that it does not afford 
fixation and the manner of contacting between the chips and frag- 
ments is more or less haphazard. The failures accompanying this 
method are much greater than when more recent technique (to be 
discussed later) is employed. It is now obsolete. 

2. The transplantation of dead bone, either as chips or in one 
large fragment. This method does not give as high a percentage 
of success as the transplanting of living bone chips and is not em- 
ployed at the present time. 

3. The transplantation of bone or periosteum by means of the 
flap method in which the graft is raised from one region, turned 
on its pedicle and inserted into the bone in which the defect is 
to be filled in. This technic[ue is difficult, limited in application 
and shows no advantage over the use of the free, periosteum-cov- 
ered transplant. It is for the most part discarded at the present 
time although there are certain conditions in which it may be used 
to advantage. Prominent among these is the filling in of defects 
in the tibia by using the fibula of the same leg and in filling in 



BONE TRANSPLANTATION 777 

defects in one of the bones of the forearm by a graft taken from 
the other bone. This will be discnssed later nnder '' Regional 
Teehniqne. ' ' 

4. The grafting of foreign materials into defects. Some remark- 
able work has been done along these lines. IMagnesium has been 
grafted into the defect and been absorbed and replaced by living 
bone. A silver framework has been made to replace a large sec- 
tion of the lower jaw and after being placed in position has been 
surronnded by bone, bnt such a result cannot be expected in any 
but the most vascular regions such as the face and even then failure 
is likely to result. Absorbable and non-absorbable materials have 
been discarded in favor of the living periosteum-covered trans- 
plant. 

AYe are warranted in employing only the methods which are 
known to produce the highest percentage of success. At the pres- 
ent time the transplantation of a large, free, periosteum-covered 
transplant is the method which produces the best results. The 
manner in which this may be accomplished has varied in the hands 
of different surgeons and according to the region involved. The 
technicjue of modern bone transplantation in the treatment of frac- 
tures may be considered under the following headings : 

1. The medullary graft or dowel method. 

2. The inlay graft. 

3. Regional or special technique in w^hich the procedure is 

adapted to certain regions. 

1. The Medullary Graft or Doivel Method. — It would seem un- 
necessary to repeat that first class operating room facilities should 
be available and that the surgeon be experienced in bone work. 
These conditions and the observance of the most rigid asepsis are 
essential. 

The fragments are exposed and the ends freshened wuth saw, 
chisel, burr, gigli saw or motor saw according to the preference of 
the surgeon. The older the fracture the more important is this 
freshening of the ends of the fragments. If the ends are much 
sclerosed it may be advisable to remove considerable bony tissue. 
If overriding deformity exists it should be corrected, when possible, 
by traction on the limb. In old cases it may be impossible to 
bring the member back to its original length and in such instances 
enough bone should be removed from the ends of the fragments 



778 



FRACTURES AND DISLOCATIONS 



to allow the overridden fragments to be brought back into align- 
ment. The medullary cavity of each fragment is then reamed out 
with a burr or drill to receive the ends of the transplant. IMurphy 
has devised special burrs for this purpose but the author has found 




Fig. 843. 



Fig. 844. Fig. 845. 

shaft with rounding of ends of frag- 



Fig. 843. — Old ununited fracture of tibi 
ments and interposition of fibrous tissue. 

Fig. 844. — Same, after ends of fragments are squared off and medullary cavity in 
fragments reamed out to receive the graft. 

Fig. 845. — Same, after medullary dowel graft has been placed in position. 



that the work may be quite satisfactorily done with an ordinary 
machinist's breast drill. 

The wound is then lightly packed with gauze, which has been 
wrung out of physiologic salt solution, and is thus protected while 
the graft is being obtained. The graft may be taken from the 
fibula, crest of ilium, upper third of posterior border of ulna. 



BONE TRANSPLANTATION 



779 



clavicle, etc., but the crest of the tibia is the favorite site and unless 
there is seme special contraindication the transplant should be 
taken from this bone. The tibia is exposed and the tibialis anticus 





Fig. 84S. 

Fig. 846. — Making saw cuts in obtaining medullary graft. The distance between 
the saw cuts represents the length of the desired graft. 

Fig. 847. — Removing medullary graft with chisel. Grooves are cut with the 
chisel and deepened until the medullary cavity is entered. The grooves should be 
deeply cut before an attempt is made to remove the graft, as otherwise it may be 
split. 

Fig.- 848. — Removing medullary graft with rotary motor saw. (See Fig. 851.) 
The saw should be kept under a stream of sterile salt" solution to prevent heating and 
devitalization of bone tissue. 



cut away from that portion of the external surface which is to be 
included in the graft. Two transverse saw cuts are made in the 
crest of the bone, the distance between them beine* the leneth of the 



780 • FRACTURES AND DISLOCATIONS 

desired graft. (See Fig. 846.) Mechanic's dividers or calipers 
are serviceable in transferring the measurement from the injured 
member to the site from which the graft is to be taken. The graft 
should be long enough to bridge the defect and extend into the 
medullary cavity of each fragment sufficiently to obtain proper 
leverage. Two grooves are next made on either side of the crest 
of the tibia and approximately parallel to it. The ends of the 
saw cuts are thus connected. A carpenter's chisel (without the 
wooden handle) makes a very satisfactory instrument for cutting 
these grooves as shown in Fig. 847. Care should be exercised in 
making these grooves, not to split the graft ; they should be deeply 
cut before an attempt is made to drive the chisel into the medullary 
cavity and thus raise the graft and separate it from the rest of the 
bone. The graft should be about the size of the index finger if it 
ia to be transplanted into one of the larger bones, and correspond- 
ingly smaller if it is to be used in one of the smaller long bones. 
The graft thus removed is trihedral, two of its sides are covered 
with periosteum while the third corresponds to the medullary cav- 
ity and is covered with endosteum. The ends are then cut with 
bone cutting forceps so that they will be slightly tapered, thus 
facilitating their introduction into the medullary cavities of the 
fragments and insuring a good fit and solid contacting between 
the graft and the fragments. The transplant should be handled 
only with instruments and should be shaped and placed in position 
as rapidly as possible. Washing the graft in salt solution is not 
advisable. After the graft is removed the wound made in securing 
it is lightly packed with moist gauze, and after the ends have been 
shaped one end of the transplant is driven into the reamed out 
medullary cavity of one of the fragments until solidly seated. 
The opposite end is then driven into the medullary cavity of the 
other fragment. When seated the graft should afford considerable 
support to the extremity. If the operation is done because of 
non-union and there is very little loss of bony tissue the fragments 
may come in contact 9ver the graft and entirely cover it. If, 
however, grafting is indicated because of loss of tissue in a shaft 
as well as non-union, it will be best to shape the graft so that the 
fragments will solidly engage with it before they come together. 
(See Fig. 845.) The graft is thus made to bridge the defect and 
overcome shortening of the member. If the shaping of the graft 
is not carefully done one or both ends may slip into the medullary 



BONE TRANSPLANTATION 781 

cavity further than desired and afford only a loose seating and 
allow shortening- of the bone. This trouble can be corrected, to 
some extent, by using nails, pegs, sutures, etc., but there is nothing 
which will take the place of a solid contacting at the proper 
points. If the graft enters a fragment too far a hole may be 
drilled transversely through the fragment and graft, and a nail 
driven in place thus holding the graft in the desired position. 
Instead of the nail a heavy strand of kangaroo tendon may be 
passed through the hole and tied about the end of the fragment. 
AYhat will answer the purpose still better, especially if Albee's 
doweling machine is at hand, will be to secure additional bone 
from the site from which the graft was taken and make from it 
a peg of bone of proper size to be driven into the hole passing 
through the end of the fragment and transplant. Foreign ma- 
terial, especially that which is non-absorbable, should be avoided as 
far as possible in fixing the graft in position since the resistance 
of the transplant is lessened by the circulatory disturbance re- 
sulting from its removal. Excellent results have been obtained 
even when the ends of the graft have been secured in position 
by nails or wire but, as previously stated in this chapter, it is 
incumbent on us to follow the methods affording the highest per- 
centage of success and the use of foreign non-absorbable materials 
in fixing the graft is more likely to be followed by trouble or 
failure than when such material is not employed. In obtaining 
the graft the work may be a little more rapidly and neatly done 
if a circular motor driven saw is used. 

In instances in which there is considerable loss of bone and the 
graft must be depended upon to maintain the length of the mem- 
ber without the ends of the fragments coming in contact, the medul- 
lary graft is probably superior to other methods. Where there 
is not great loss of bony tissue and the element of non-union is the 
important factor better results are claimed for the inlay graft. 

2. The Inlay Graft. — (Albee's technique.) The fragments are 
exposed and the ends freshened as already described in preparing 
the fragments for the medullary graft. It is an extremely diffi- 
cult matter to carry out this technique without the twin motor 
saw as used by Albee and if such is not available one had better 
employ the medullary graft. 

A longitudinal incision is made through the periosteum and the 
edo'es turned back to expose the cortex of the bone in which the 



782 



FRACTURES AND DISLOCATIONS 



gutter is to be cut to receive the graft. Two longitudinal parallel 
saw cuts are made with the twin saws across the plane of frac- 
ture and extending into each fragment for a distance ol two and a 
half to three inches. These cuts pass through the cortex into the 





Fig. 849. 



Fig. 850. 



Fig. 849. — Inlay graft in place. Albee's technique in cases of non-union. The 
twin motor saws are almost essential in cutting the gutter to receive the graft and in 
obtaining the graft from the tibia. 

Fig. 8.50. — Method of securing inlay graft in place -with kangaroo tendon as advo- 
cated by Albee. 



medullary cavity of the fragments. Care should be exercised in 
using the saws to see that they follow straight lines as otherwise the 
gutter will show a lateral curvature which will be difficult to fit 
with the graft. Albee advises that the saws be adjusted to a dis- 
tance of %6 to %6 of 'an Inch from each other according to the 
size of the bone operated upon. In cutting the groove the saws 
should be kept under a stream of salt solution to prevent heating 
of the bone which tends to devitalize it. The bone is finally re- 
moved from the groove by cutting the ends with a small osteotome 
so as to make a tongue and groove. (See Fig. 849.) Either two 



BONE TRANSPLANTATION 



783 



or four holes (according' to the needs of the case) are then diago- 
nally drilled through the cortex on both sides of the groove and in 
both fragments. These holes are drilled in pairs opposite each 
other, as sho^Yn in Fig. 849, and through each pair of holes is passed 
a double strand of heaw kangaroo tendon. The fragments are 
now ready for the graft. The Avound is then lightly packed with 




Fig. 851. — Motor saw equipment including twin saws. 




Fig. 852. — Doweling machine. 

moist gauze and the surgeon turns his attention to securing the 
graft to fill the gutter. 

The internal surface of the tibia is next exposed and the dimen- 
sions of the desired graft are mapped out on the periosteum with 
a scalpel. The twin saws are then employed (without changing 
their adjustment) and a strip of bone, the same size as the gutter 
prepared in the fragments, is removed. The ends of this graft 
are then pointed with the saw to conform to the ends of the groove 
in the fragments. The graft is next transferred and the wound 
filled with a moist pack. One strand of kangaroo tendon is then 



784 



FRACTURES AND DISLOCATIONS 



pulled up from the medullary cavity between each pair of holes 
previously drilled in the fragments and the graft placed under 
these raised strands. The ends of the sutures projecting from the 
drill holes are tied and the graft thus secured in place. (See Figs. 
849 and 850.) The tongue and groove effect at the ends of the 
graft causes the ends of the transplant to become firmly engaged 
when extension is removed and the muscles of the extremity con- 





Fig. 853. 



Fig. 854. 



Fig. 855. 



Fig. 853. — First step in Albee's technique in recent fractures. Superficial cuts 
are made with the twin saws and then each cut is finished with a single rotary saw 
so that the section of bone removed will be wedge-shaped. 

Fig. 854. — Second step. Short piece is removed to be cut up longitudinally to 
be used in making bone pegs with the doweling machine. A. shows short piece removed. 

Fig. 855. — Third step. Long piece has been slid to opposite end of gutter so 
that it crosses the line of fracture and is held in place by means of obliquely driven 
bone pegs. B. is a cross-section showing manner in which oblique pegs hold graft. 



tact, while the kangaroo tendon sutures maintain the fragments 
and graft in alignment. The older the case of non-union and the 
more sclerosed or eburnated the ends of the fragments, the longer 
the graft should be, thus insuring bone-forming activity by extend- 
ing well into the substance of each fragment. It is claimed that 
this method gives better results in old cases of non-union because 



BONE TRANSPLANTATION 785 

of the greater surface of contact between graft and fragments. On 
the other hand it is certain that the inlay graft does not occupy 
as good a position from a mechanical standpoint as does the medul- 
lary transplant, and when heavy muscular contraction and shorten- 
ing are to be overcome (as in fracture of the femur) the latter 
will be found the safer techniciue. It is probably not wise to 
attempt the inlay method unless the motor saw equipment is avail- 
able. 

Albee's Technique in Eecent Fracture. — Albee employs a modi- 
fied inlay graft in the operative treatment of recent fractures. 
The twin motor saw and the doweling machine are essential to this 
technique. The fragments are exposed and approximated. With 
the twin motor saw (the blades being adjusted to about Y-^q of an 
inch apart) two longitudinal superficial cuts are made crossing 
the line of fracture as shown in Fig. 853. The saws should follow 
straight lines and the cuts should extend about twice as far on 
one side of the plane of fracture as on the other. A single motor 
saw is then used to complete the cuts into the medullary cavity. 
The cuts are not made in parallel planes but are so placed that 
the periosteal surface of the graft is about one-fourth of an inch 
wider than is the endosteal surface. Thus by making a wedge of 
the graft it will be impossible for it to be displaced into the medul- 
lary cavity. The short piece of the graft is removed and the 
long piece slipped to the opposite end of the groove so that it 
crosses the line of fracture. (Fig. 855.) The short piece of the 
graft is then cut up with the motor saw and converted into pegs 
with the doweling machine. Oblique holes are next drilled into 
the fragments on each side of the graft and the bone pegs driven 
home so that their ends project over the graft. (See Fig. 855.) 
Good fixation is thus afforded if the technique is properly carried 
out and the great claim for this method is that no foreign material 
is left imbedded in the wound. Albee recommends this method 
as a substitute for the Lane plate. 

3. Regional or Special Technique. — The methods just described 
will meet the indications in practically all of the fracture cases in 
which bone grafting is indicated. The various modifications which 
have . been employed in different regions of the skeleton have in 
almost all cases been devised to correct conditions resulting from 
disease or defective development, and hence cannot be properly 
considered as coming within the scope of this work. If the sur- 



786 



FRACTURES AND DISLOCATIONS 



ct=b» 



geon appreciates the principles involved in bone 
grafting* and the technique of the dowel and inlay 
grafts he will be able to modify his technique to 
meet the exceptional case. Some of the more com- 
mon variations may be mentioned. The entire 
upper end of the humerus has been replaced with 
the upper end of the fibula. A longitudinal in- 
cision exposes the region previously occupied by 
the upper end of the humerus. The end of the 
fragment is freshened and its medullary cavity 
reamed out. The upper end of the fibula is next 
exposed and the length of the desired graft 
marked on its shaft. It is then cut across and the 
cut end inserted into the reamed out medullary 
cavity of the humerus while the ligaments and 
muscles of the shoulder are sutured about the 
upper end of the bone when placed in the glenoid 
cavity. In a similar manner the lower end of the 
radius has been replaced by transplanting the 
upper end of the fibula. The shaft of the tibia 
may be replaced by the shaft of the fibula without 
completely detaching the fibular shaft from its 
surrounding soft tissue. The operation is usually 
done in two stages though it may be done in one. 
The lower end of the upper tibial fragment is ex- 
posed, the end freshened and the medullary cav- 
ity reamed out. The upper end of the fibula is 
then divided and carried across to be inserted into 
the upper tibial fragment and the wound closed. 
The second step of the operation consists in trans- 
planting the lower divided end of the fibula into the lower tibial 
fragment. The entire tibia has been replaced in congenital ab- 
sence of this bone by using the fibula. The upper end of the fibula 
is placed against the femoral condyles while the lower end of the 
bone is placed against the astragalus. In loss of bony tissue in one 
of the bones of the forearm (e.g., the shaft of the radius) a section 
of the shaft has been raised from the ulna and grafted into the 
radial defect without severing the pedicle attached to the trans- 
plant. In an operation of this kind only a portion of the shaft of 
the ulna should be removed. In old ununited fracture of the neck 




^56. 



Dia- 



gram, showing man- 
ner in which upper 
end of humerus may 
be replaced by 
grafting of upper 
end of fibula. Sel- 
dom called for in 
the treatment of 
fractures but illus- 
trates one of the 
adaptations of bone 
grafting. 



BONE TRANSPLANTATION 787 

of the femur excellent results have heen obtained by driving a 
graft taken from the tibial crest through the trochanter and neck 
of the bone. The principles involved are the same as described in 







Fig. 857. Fig. 858. 

Fig. 857. — Loss of tibial shaft. 

Fig. 858. — First step in replacing tibial shaft by shaft of fibula. The fibular 
shaft* is divided and implanted into the upper tibial fragment. 

Fig. 859. — Completion of operation. The lower end of fibular shaft has been im- 
planted into lower tibial fragment. 

the ''Operative Treatment" of ''Fractures of the Upper End of 
the Femur" (page 550), except that a graft is used instead of a 
screw or "screw-plate." The knee has been replaced by the same 
joint taken from a freshly amputated leg and the metatarso- 
phalangeal joint has been excised and grafted into an ankylosed 
elbow of the same patient. 



788 FRACTURES AND DISLOCATIONS 

It is manifestly impracticable at the present time to enter into 
all the possible variations of bone gi^afting and a consideration of 
the conditions in which it may be indicated. If the principles of 
this procedure are understood and the conditions under which it is 
most likely to be successful are fully appreciated the surgeon's 
mechanical sense and ingenuity should be sufficient to enable him 
to modify his techniciue to meet the requirements in a given case 
of exceptional needs. 



CHAPTER LXI. 

TREATMENT OF COMPOUND FRACTURES 
AND DISLOCATIONS. 

The advent of asepsis and the improved technique of recent years 
has greatly reduced the percentage of bad results, previously so 
high, following compound fractures and luxations. Compound 
fractures are common, but it is unusual to see a dislocation which 
exposes the joint except in luxations of the fingers. The more com- 
mon luxations are almost invariably closed. 

The principles involved in treatment are practically the same 
whether the condition be a fracture or dislocation, and accordingly 
the two conditions will be considered together. Immediate reduc- 
tion is the natural tendency as soon as the case is seen but in 
many instances nothing more detrimental could be done. The 
exposed fragment or articular surface must be considered infected, 
and if immediately replaced is almost sure to be followed by sup- 
puration of the tissues with which it has come in contact. ]\Iany 
compound fractures and dislocations are produced by penetration 
from without, and in these cases we do not have to deal with a 
projecting fragment or articular end. 

When a compound fracture or luxation is first seen the wound 
should be covered with a sterile dressing and the patient removed to 
surroundings in which proper surgical procedures can be carried 
out. Sterile surgical dressings may not be at hand, in some in- 
stances, and in lieu of these a towel fresh from the laundry is a 
safe substitute to use in covering the wound. The heat of ironing 
sterilizes the towel fairly well, especially as done in the modern 
steam laundry, and if the towel is unfolded so that a fresh surface 
comes in contact with the wound there will be little danger of infec- 
tion from the dressing, and the wound will be properly protected 
during transportation. 

An anesthetic is advisable in most cases. With the patient in 
the operating room the dressings are removed and the skin sur- 
rounding the wound painted with a five percent tincture of iodine. 
The edges of the wound are then inspected, and if lacerated and 

789 



790 FRACTURES AND DISLOCATIONS 

devitalized tissue is present it should be trimmed away until the 
margins present healthy viable tissue. If a fragment or the artic- 
ular end of a bone projects through the wound it should be thor- 
oughly washed with sterile physiologic salt solution until all foreign 
material has been removed. A few gallons of salt solution are not 
too much. The usual fault lies in too little washing. After the 
projecting bone has been thoroughly cleaned reduction is effected 
and the wound again washed with a few gallons of sterile salt solu- 
tion. Internal fixation of the fragments should not be done at 
this time. Foreign materials should not be employed to secure 
fixation unless one is sure of asepsis within the wound, and in 
compound fractures the surgeon can never be sure of this point. 
It is often possible to obtain a solid engagement of the serrated ends 
of the fragments so that the deformity does not recur when proper 
splints are applied. "When, however, the fragments cannot be held 
in good reduction it is better to close the wound, obtain healing 
of the soft tissues and perform a secondary operation at a later date, 
when the danger of infection has passed. In favorable cases the 
wound will be healed within a week or ten days and the surgeon 
may then expose the fragments by incision and employ internal 
fixation as already described in the ''Operative Treatment of Frac- 
tures" on page 758. 

In cases in which suppuration follows, internal fixation can 
accomplish no good and is capable of doing considerable harm. 
There is nothing lost, therefore, when internal fixation is not em- 
ployed at the first operation even in the presence of recurrent 
deformity. 

The essentials in the operative treatment of compound fractures 
and dislocations are the thorough and free washing of the wound 
and the trimming away of lacerated and devitalized tissue. The 
living tissues possess a certain amount of resistance to infection 
which increases during the first few days following the injury, but 
devitalized tissue and collections of dead blood within the wound 
possess no such resistance but act only as culture media for the 
development of the slight infection which remains even after the 
most painstaking attempt at removal and cleansing. The use of 
antiseptics within the wound, such as solutions of bichlorid of mer- 
cury, are not only useless but actually harmful. They not only 
have little influence on the bacteria but materially reduce the resist- 
ance of the tissues. 



TREATMENT OF COMPOUND FRACTURES AND DISLOCATIONS 791 

By careful attention to these two points (washing and removal of 
devitalized tissue) the proportion of cases in which suppuration 
follows in compound cases will be surprisingly reduced. When, 
however, suppuration follows in spite of this treatment drainage 
should be prompt and free, and attention should be given to the 
cultivation of granulation tissue so the wound may heal from the 
bottom in the shortest time possible. The fact that the wound is 
infected does not mean that the asepsis employed in the dressing 
of the wound should be anything but the most rigid. Even though 
suppuration is present it should not be forgotten that it is possible 
to introduce bacteria of other strains which are sometimes produc- 
tive of the most disastrous results. For example a compound frac- 
ture may be infected with pyogenic bacteria and still be making 
good progress toward recovery ; if some virulent infection, such as 
erysipelas or the gas bacillus, gains entrance to the wound the 
termination may be fatal within a short time. 

The use of the so-called antiseptics within the wound are as use- 
less and harmful here as in the initial treatment of the wound. The 
chief concern, after. suppuration is established, is in the cultivation 
of granulation tissue so that the wound will heal from the bottom 
and cover the fragments. In order that this may be accomplished 
drainage should be free and fluids coming in contact with the gran- 
ulation tissues should be isotonic, and the dressings should not 
adhere to and tear the granulation tissue when removed. Accord- 
ingly physiological sterile salt solution should be used in irrigating 
the wound, and balsam of Peru is one of the best materials to stim- 
ulate the granulation tissue and prevent it from adhering to the 
dressings. Infection in a compound fracture is decidedly detri- 
mental to union between the fragments, but it does not necessarily 
mean that non-union will take place. Many cases are shown in 
the preceding pages in which infection was present and still perfect 
union took place. In some fractures there may be considerable 
destruction of tissue in the wound which renders the condition com- 
pound, and in such cases it is often advisable to do a plastic sliding 
operation so the wound may be closed even at the expense of leaving 
some adjoining region partially denuded. 

In compound luxations the cleansing and trimming away of 
lacerated tissue involves the same principles as already described. 
If suppuration develops subsequently the joint should be aspirated 
and injected with Murphy's formalin-glycerine solution. IMore 



792 FRACTURES AND DISLOCATIONS 

than one aspiration and injection may be necessar}^ during the 
after-treatment, especially if the joint leaks through the wound 
following the first injection. The solution injected is two percent 
formalin in glycerine and should be made up the day before it is 
used. Enough of the fluid should be injected to gently distend 




-Fiji. •■^fifJ. — (Tungrene following tliromljosis. 

the articulation. ]\Iurphy has demonstrated that this treatment of 
suppurative arthritis gives a much higher percentage of good func- 
tional results, and should always be tried out before open drainage 
of the joint is resorted to. When open drainage is established the 
result is almost invariably a stiff joint. 

The results in compound fractures and dislocations depend 
largely on the operative treatment immediately following the 
injury, and too much stress cannot be laid on the thorough washing 
of the wound and the trimming away of lacerated and devitalized 
tissue. 



INDEX 



Abscess of brain, 443 

following fracture of skull, 450 
symptoms of, 443 

ditferential diagnosis of, in frac- 
ture of skull, 443 
Absorbable suture material, 768 
Acetabulum, fracture of, 499 

complicating dislocation of hip, 
520, 524 
Acromion, fracture of {see Fracture 

of scapula, 37 ) 
Acute flexion of elbow, in treatment 
of fractures of elbow, 144, 
145 
Adjustable splints for fracture near 

elbow, 148 
After-care {see After-treatment) 
After-treatment in, 

dislocation of, ankle, 690 
astragalus, 698 
calcaneum, 707 
carpo-metacarpal joint, 296 
clavicle, inner end, 10 

outer end, 36 
cuboid, 712 

cuneiform, 292 {see Carpus) 
cuneiforms of tarsus, 712 
elbow, 171 
fingers, 318 
hip, 530 
jaw, 378 
knee, 619 
mandible, 378 
maxilla, 378 
OS calcis, 707 
phalanges, of foot, 720 

of hand, 318 
radius, head of, 182 
scaphoid, of carpus, 292 
of tarsus, 712 
milunar ca 
shoulder, 79 
spine, 490 

subastragalar joint, 702 
subcoracoid of shoulder, 79 
subglenoid of shoulder, 79 
ulna, lower end, 240 
upper end, 176 



793 



After-treatment, dislocation— cont'd, 
wrist, 292 
fracture of, 
astragalus, 698 
calcaneum, 707 
carpus, 292 
clavicle, 28 
cuboid, 712 
cuneiforms, 721 
femur, lower end, 784 

shaft, 572 

upper end, 552 
fibula, lower end, 683 {see Tibia 
and Fibula) 

shaft, 654 

upper end, 631 
inferior maxilla, 375 
jaw, lower, 375 

upper, 346 
malar, 342 
maxilla, inferior, 375 

superior, 346 
metacarpals, 306 
metatarsals, 718 
nasal bones, 332 
olecranon, 190 
OS calcis, 707 
patella, 605 

phalanges of hand, 312 
radial and ulnar shafts, 228 
radius, lower end, 271 

shaft, 228 

upper end, 202 
ribs, 463 
scaphoid, 292 
scaphoid of tarsus, 712 
scapula, 43 
semilunar, 292 
semilunar 
spine, 490 
sternum, 458 
superior maxilla, 346 
tibia and fibula, lower ends, 683 

shafts, 654 

upper ends, 631 
ulna, lower end, 235 

shaft, 228 

upper end, 195 
zygomatic arch, 342 



794 



INDEX 



Aljlee's, inlay graft, 781 

inlay graft in recent fractures. 785 
Allis' method of reducing disloca- 
tions of hip, 528 
Ambulatory pneumatic splint, 
for fracture of hip, 554 
for fracture of leg, 655 
for fracture of thigh, 585 
Anatomical neck of humerus, frac- 
ture of, 83 
Angle's bands, in treatment of frac- 
tures of jaw, 371, 372 
Angle's bands and bars, in treat- 
ment of fractures of jaw. 
371, 372 
Ankle, fracture-dislocations of, C84 
after-care, 690 
diagnosis, 689 
prognosis, 691 
surgical anatomy, 684 
symptoms, 687 
treatment. 689 

after-treatment. 690 
operative treatment. 600 
Anomalies of carpus. 283 
Anomalous ossification of upper end 

of tibia, 622 
Apoplectiform attacks, different' ated 
from unconsciousness in 
fracture of skull, 443 
Asche nasal splints, 329 
Apoplexy differentiated from uncon- 
sciousness in fracture of 
skull, 440 
Astragalus, fractures and disloca- 
tions of, 692 
after-care, 698 
diagnosis, 695 
prognosis, 698 
surgical anatomy, 692 
symptoms, 694 
treatment, 695 

after-treatment, 695 
operative treatment. 607 
Atlas (see Fracture-dislocations of 

spine. 465) 
Author's method of reduchiQ- disloca- 
tions of hip, 526 
nasal snlint, 330 
screw-plate, 550, 551 
Avulsion of upper extremity. 63 
Axillary pad. 98 

Axis {see Fracture-dislocations of 
spine, 465 ) 



B 



Bandage, fourtailed, for fracture of 
jaw, 358 



Bandage, — con fd. 

Mohr's figure-of-eight, 25 
Stimson's. for dislocation of clav- 
icle, 35 
Velpeau's, 25 

in fracture of clavicle, 9 
Barton's fracture, 251 
Base-ball finger, 309 
Base of skull {see Skull, fracture of, 

391) 
Battle's sign, 420 
Bauer's qualimeter, 746 
Bed-sores, in fractures of spine, 490 
Bennett's fracture, 299 
Benoist. radio-chronometer, 746 
Bigelow's method of reducing dislo- 
cation of hip, 526 
Y-ligament of, 516 
Blebs, in fracture near elbow, 129 

in fracture of leg, 640 
Bodv swathe, in fracture of humerus, 
101, 114 
in fracture, of pelvis, 507 

of ribs, 463 
used with T-splint. 544 
Bone drill, Lane's, 760 
Bone forceps, 761 

Bone graftino- {see Bone transplan- 
tation, 771) 
Bone plates, Lane's, 766 

Sherman's modification of, 765 
Bone, structure of, 
in clavicle, 12 
in femur, 531, 575 
in humerus, 83 
in radius. 204 
in tibia, 727 
in ulna, 204 
Bones of carpus, iniuries to, 277 

anomalies of, 282 
Bone transplantation, 771 
technique of, 776 

Albee's method, for nonunion in 
recent fractures, 785 
medullarv graft, 775, 777 
theories of, 771 
Brace. Tavlor's. for fractured clavi- 

'cle, 27 
Brain, anatomv of ( s^e Skull, frac- 
ture of, 392) 
abscess of brain, symptoms of. 443 

differential diaonosis of, 450 
compression of. 410 
concussion of, 407 
contusion of, 408 
injury to, 411 
laceration of, 409 
membranes of. 395 
Bryant's triangle, 534 
Buck's extension. 542 



INDEX 



795 



Cabot's wire splint, 

as double inclined plane, 580 
fracture o 
of leg. 046 
in Fott s fracture, 6(39 
Calcaneum, fractures and disloca- 
tions of, 703 
after-care, 707 
diagnosis, 706 
prognosis, 708 
surgical anatomy, 703 
symptoms, 705 
treatment, 706 

after-treatment, 707 
operative treatment, 706 
Carcinoma, cause of fracture, 728, 

729, 731 
Carpal bones [see Carpus, 277) 
Carpo-metacarpal dislocations, 294 
atter-care, 296 
diagnosis, 295 
prognosis, 296 
surgical anatomy, 294 
symptoms, 295 
treatment, 296 

after-treatment, 296 
operative treatment, 296 
Carpus, injuries to, 277 
after-care, 292 
diagnosis, 290 
prognosis, 293 
surgical anatomy, 277 
symptoms, 287 
treatment, 291 

after-treatment, 292 
operative treatment, 292 
Carrying angle, loss of, 128 
Cartilages, semilunar, fractures and 

dislocations of, 587 
Cast, plaster, for fracture of hip, 546 
in fracture of leg, 649 
in fracture of pelvis, 509 
in fracture of spine, 484 
with arm in abduction, 103 
with thigh in abduction, 548 
with thigh in semiflexion, 548 
Cerebrospinal fluid, escape of, in frac- 
ture of skull, 417 
Chest, injuries to, 

{see Fractures of ribs, 459) 
(see Sternum, 453) 
Clamp, four-post, 763 
Clavicle, dislocation of inner end, 5 
after-care, 10 
diagnosis, 7 
prognosis, 10 
surgical anatomy, 5 
symptoms, 6 



Clavicle — cont'd. 
treatment, 7 

after-treatment, 10 
operative treatment, 9 
dislocation of outer end, 30 
after-care, 36 
diagnosis, 33 
prognosis, 36 
surgical anatomy, 30 
symptoms, 32 
treatment, 34 

after-treatment, 36 
operative treatment, 36 
fracture of, 11 
after-care, 28 
diagnosis, 22 
prognosis, 29 
surgical anatomy, 11 
symptoms, 15 
treatment, 22 

after-treatment, 2i8 
operative treatment, 26 
Coaptation splints, for fracture, 
of humerus, 115 
of femoral shaft, 567 
Cobb's nasal splint, 330 
Coccyx, fracture-dislocations of, 500 

treatment, 507 
Colles' fracture (see Radius, fracture 

of lower end, 242) 
Coma, in head injuries, 420 
from alcohol, 433 
from asphyxia, 435 

belladonna and its alkaloids, 436 
chloral, 435 

hyocyamus and its alkaloids, 436 
lead poisoning, 436 
morphine, 434 
opium, 434 
phenol, 434 
reflex causes, 438 
in abscess of brain, 443 
acute exanthemata, 438 
apoplexy, 440 
cerebral anemia, 432 
cerebral congestion, 432 
cerebral embolism, 440 
cerebral hemorrhage, 441 
cerebral meningitis, 443 
cerebral syphilis, 442 
cerebral thrombosis, 441 
diabetes, 437 
epilepsy, 439 
feigning, 438 
hysteria, 438 
pneumonia, 438 
ptomaine poisoning, 435 
shock, 431 
syncope, 431 
tumor of brain, 443 



796 



INDEX 



Coma, in — cont'd. 
typhoid, 438 
Complications in fracture of pelvis, 
509 
rupture, of bladder, 510, 511, 512 
of urethra, 509, 510 
Compound fractures and dislocations, 
789 
treatment of, 789 
Compression of brain, 410 
Concussion of brain, 407 
Contracture following, Colles' frac- 
ture, 275 
dislocation of shoulder, 76 
injury to brachial plexus, 76 
injury to musculo-spiral, 140 
Volkmann's paralysis, 231 
Contusion of brain, 408 
Coracoid process {see Scapula, frac- 
ture of, 37) 
Coronoid process {see Ulna, fracture 
of upper end, 188) 
fracture of, complicating disloca- 
tions of elbow, 166, 167 
Coxa vara, 556, 557 
Cradle, 646 

Cranial nerves, passage through 
skull, 344 
symptoms of injury to, 425 
Crepitus {see Symptoms of region in 

question ) 
Crookes tube, 740 

Crushes of carpus {see Carpus, inju- 
ries to, 287) 
of tarsus, 710 
Cubitus, valgus {see Humerus, frac- 
tures of lower end, 142) 
varus {see Humerus, fractures of 
lower end, 142) 
Cuboid, fractures and dislocations of, 

710 
Cuneiform {see Carpus, injuries to, 

281, 2186, 289) 
Cuneiforms of tarsus, fractures and 
dislocations of, 710 



D 



Davison's method for fracture of fe- 
mur in children, 565 
Diagnosis of, 

dislocations of, ankle, 689 
astragalus, 695 
calcaneum, 706 
carpo-metacarpal joint, 295 
clavicle, inner end, 7 

outer end, 33 
elbow, 163 
fingers, 315 
hip, 523 



Diagnosis of, dislocations — cont'd. 
OS calcis, 706 
patella, 611 
pelvis, 505 

phalanges of hand, 315 
radius, head of, 180 
semilunar cartilages, 590 
shoulder, 64 
spine, 483 

subastragalar joint, 701 
subcoracoid, of shoulder, 64 
subglenoid, of shoulder, 64 
tarso-melatarsal joint, 713 
ulna, lower end, 239 
wrist, 290 
fracture of, 

astragalus, 695 

calcaneum, 706 

carpus, 290 

clavicle, 22 

coccyx, 506 

femur, lower end, 579 

shaft, 562 

upper end, 539 
fibula, lower end, 666, 679, 689 

shaft, 642 

upper end, 627 
fingers, 310 
hip, 539 
humerus, lower end, 136 

shaft. 111 

upper end, 95 
inferior maxilla, 356 
jaw, lower, 356 

upper, 345 
metacarpals, 300 
metatarsals, 718 
malar, 338 
maxilla, inferior, 356 

superior, 345 
nasal bones, 327 
olecranon, 190 
patella, 597 
pelvis, 505 

phalanges of hand, 310 
radial and ulnar shafts, 219 
radius, lower end, 260 

shaft, 219 

upper end, 200 
ribs, 462 
scapula, 41 

semi-lunar cartilages, 590 
spine, 483 

superior maxilla, 345 
tibia and fibula, lower ends, 666. 
679, 689 

shafts, 642 

upper ends, 627 
ulna, lower end, 234 

shaft, 219 



INDEX 



797 



Fibula, ulna — confd. 
upper end, 190 
zygomatic arch, 388 
in Colles' fracture, 260 
in injuries to carpus, 290 
in Pott's fracture, 666 
Definitions and terms, 725 
Deformity {see Symptoms, under 
fractures and dislocations 
of various bones and 
joints) 
Deformitv, garden-spade, 244 

gunstock, 135, 138, 142, 158, 201 
in Barton's fracture, 257 
in Bennett's fracture, 229, 230 
in Colles' fracture, 252-262 
in dislocation of wrist, 262, 287 
in Pott's fracture, 664, 665, 666, 

667 
in Volkmann's contracture, 230 
Madelung's, 239 
silver-fork, 247, 252-262 
Desault splint, 645 
DeVilbiss forceps, 448 
Dislocatio erecta, 60 
Dislocation of, acromioclavicular 
joint, 30 
ankle, 684 (see iVnkle) 
astragalus, 692 {see Astragalus) 
calcaneum, 703 {see Calcaneum) 
carpal bones, 277 {see Carpus) 
carpo-metacarpal joint, 294 
cervical vertebrae, 465 {see Spine) 
clavicle {see Clavicle) 
inner end, 5 
outer end, 30 
coccyx, 500 {see Pelvis) 
costal cartilages, 460 {see Ribs) 
cuboid, 710 
cuneiforms, 710 
elbow, 154 {see Elbow) 
fingers, 314 {see Fingers) 
head of humerus, 44 {see Shoul- 
der) 
head of radius, 177 {see Radius) 
hip, 515 {see Hip) 
inferior maxilla, 376 {see Maxilla, 

inferior ) 
jaw, 376 {see Maxilla, inferior) 
knee, 613 {see Knee) 
medio-tarsal joint, 709 
OS calcis, 703 {see Calcaneum) 
patella, 609 {see Patella) 
pelvis, 492 {see Pelvis) 
phalanges of foot, 720 {see Toes) 
radius {see Radius) 

upper end, 177 
radius and ulna, divergent, 154 

{see Elbow) 
scaphoid, 710 



Dislocation of — confd. 

semilunar cartilages, 587 {see 

Semilunar cartilages ) 
shoulder, 44 {see Shoulder) 
spine, 465 {see Spine) 
subastragalar joint, 699 
sternal end of clavicle, 5 
thumb, 314 
ulna, lower end, 237 

upper end, 175 
wrist, 277 {see Carpus) 
Drainage, in operative treatment of 
fractures, 758 
in treatment of compound fractures 
and luxations, 790 
Dupuy's splint for fracture of lower 

extremity, 581 
Dupuytren's splint, 668 



E 



Ecchymosis, in fracture of clavicle, 
21 
humerus, 89, 96 
leg, 640 
olecranon, 190 
skull, 418, 420 
Edmund's forceps, 364 
Elbow, dislocations of, 154 
after-care, 171 
diagnosis, 163 
fracture complicating, 156 
prognosis, 174 
surgical anatomy, 154 
symptoms, 156 
treatment, 167 

after-treatment, 171 
operative treatment, 170 
Embolism, fat, 642 

Emergency treatment, of fracture of 
leg, 642 
of thigh, 563 
Emphysema, in fracture of, malar 
and superior maxilla, 338, 
344 
nasal bones, 326 
ribs, 462 
Epilepsy, as a cause of unconscious- 
ness, 439 
following fracture of skull, 451 
treatment of, 451 
Epileptic unconsciousness, difi'eren- 
tiated from coma accom- 
panying head injuries, 
439 
Epiphyseal separations, considered 
under fracture of bone in 
question {see Fracture) 
Epiphysis of, acromion, 37 
clavicle, 11 



798 



INDEX 



Epiphysis of — cont'd. 
coracoid, 38 
femur, lower end, 576 

upper end, 531 
humerus, lower end, 125 

upper end, 88 
metacarpal boues, 297 
metatarsal bones, 714 
pelvis, 492 

phalanges of fingers, 307 
radius, lower end, 251 

upper end, 198 
scapula, 37 
tibia and fibula, lower ends, 676 

upper ends, 622 
ulna, lower end, 232 
upper end, 186 
Erect dislocation of shoulder, 60 
Etiology of, 

dislocation, of hip, 520 
inferior maxilla, 377 
patella, 610 
fracture of, femoral shaft, 560 
upper end, 534 
humerus, upper end, 89 
inferior maxilla, 350 
malar, 336 
nasal bones, 325 
patella, 595 
pelvis, 496 

tibia and libula, shafts, 637 
upper ends, 624 
Everted dorsal dislocations of hip, 

519 
Examination ( see Diagnosis ) 
Face, fracture T of bones of, • 
malar, 334 
maxilla, inferior, 348 

superior, 343 
nasal, 323 
Facial, artery, injury to, 350 

nerve, injury to, 350 
Fat embolism, 642 
Feeding after fracture of inferior 

maxilla, 375 
Femur, 

dislocation of lower end, 613 {see 
Knee) 
upoer end, 515 {see Hip) 
fracture of, lower end, 574 
after-care, 584 
diagnosis, 579 
prognosis, 586 
surgical anatomy, 574 
symptoms, 578 
treatment, 580 

after-treatment, 584 
operative treatment, 582 
shaft, 558 

after-care, 572 



Femur, shaft — cont'd. 
diagnosis, 562 
etiology, 560 
in children, 568 
in new-born, 568 
prognosis, 573 
surgical anatomy, 558 
symptoms, 561 
treatment, 563 

after-treatment, 572 
operative treatment, 569 
upper end, 531 
after-care, 552 
diagnosis, 539 
in children, 555 
prognosis, 555 
surgical anatomy, 531 
symptoms, 537 
treatment, 542 

after-treatment, 552 
operative treatment, 550 
Fingers, base-ball, 309 
Fingers, dislocation of, 314 
after-care, 318 
diagnosis, 315 
prognosis, 319 
surgical anatomy, 314 
symptoms, 317 
treatment, 317 

after-treatment, 318 
operative treatment, 318 
fractures of, 307 
after-care, 312 
diagnosis, 310 
prognosis, 313 
surgical anatomy, 307 
symptoms, 308 
treatment, 310 

after-treatment, 312 
operative treatment, 311 
Fissure of Eolando, 401 
Flap, osteoplastic of, skull, 447 

of spine, 488 
Flat-foot, traumatic, 673, 703 
Forceps, DeVilbiss, 448 

Edmund's, 364 
Forearm, fracture of shafts of bones 
of, 204 {see Radial and 
Ulnar shafts) 
Four-post clamp, 763 
Freeman's, 764 
Durtailed I 
Fracture of, 

acetabulum, 499 {see Pelvis) 

complicating luxation of hip, 582 
acromion process, 40 {see Scapula) 
accompanying upward luxation 
of shoulder, 51 
anatomical neck of humerus, 90 
astragalus, 692 



INDEX 



799 



Fracture of, astragalus — cont'd. 
after-care, 698 
diagnosis, 695 
prognosis, 698 
surgical anatomy, 692 
symptoms, 694 
treatment, 695 

after-treatment, 698 
operative treatment, 697 
Barton's, 251 
Bennett's, 299 
caleaneum, 703 
after-care, 707 
diagnosis, 706 
prognosis, 708 
surgical anatomy, 703 
symptoms, 705 
treatment, 706 

after-treatment, 707 
operative treatment, 706 
carpal bones, 277 
after-care, 292 
diagnosis, 290 
prognosis, 293 
surgical anatomy, 277 
symptoms, 287 
treatment, 291 

after-treatment, 292 
operative treatment, 292 
clavicle, 1 1 
after-care, 28 
diagnosis, 22 
prognosis, 29 
surgical anatomy, 11 
symptoms, 15 
treatment, 22 

after-treatment, 22 
operative treatment, 26 
coccyx, 500 (see Pelvis) 

treatment, 507 
coracoid process, 38 (see Scapula) 
cuboid, 710 

after-care, 712 
prognosis, 712 
surgical anatomy, 710 
treatment, 710 

after-treatment, 712 
operative treatment, 712 
cuneiforms, 710 

treatment, 710 
femur, lower end, 574 
after-care, 584 
diagnosis, 579 
prognosis, 586 
surgical anatomy, 574 
symptoms, 578 
treatment, 580 

after-treatment, 584 
operative treatment, 582 
shaft, 558 



Fracture of, femur, shaft — cont'd. 
after-care, 572 
diagnosis, 562 
etiology, 560 
in children, 568 
in the new-born, 5618 
prognosis, 573 
surgical anatomy, 558 
symptoms, 561 
treatment, 563 

after-treatment, 572 
operative treatment, 569 
upper end, 531 
after-care, 552 
diagnosis, 539 
etiology, 534 
in children, 555 
prognosis, 555 
surgical anatomy, 531 
symptoms, 537 
treatment, 542 

after-treatment, 552 
operative treatment, 550 
fibula {see Tibia and Fibula) 
lower end, 675 
shaft, 634 
upper end, 620 
lingers, 307 
after-care, 312 
diagnosis, 310 
prognosis, 313 
surgical anatomy, 307 
symptoms, 308 
treatment, 310 

after-treatment, 312 
operative treatment, 311 
forearm, bones of, 184 {see Radius 

and Ulna) 
hip, 531 {see Femur) 
humerus, anatomical neck of, 90 
lower end, 120 
after-care, 151 
diagnosis, 136 
prognosis, 152 
surgical anatomy, 120 
symptoms, 128 
treatment, 143 

after-treatment, 151 
operative treatment, 148 
shaft, 108 

after-care, 119 
diagnosis. 111 
prognosis, 119 
surgical anatomy, 108 
symptoms, 110 
treatment, 113 

after-treatment, 119 
operative treatment, 110 
upper end, 82 
after-care, 106 



800 



INDEX 



Fracture of, humerus, upper end — 
confd. 
diagnosis, 95 
prognosis, 107 
surgical anatomy, 82 
symptoms, 89 
treatment, 97 

after-treatment, 106 
operative treatment, 104 
ischium, 500 
malar, 354 
after-care, 342 
diagnosis, 338 
etiology, 336 
prognosis, 342 
surgical anatomy, 334 
symptoms, 336 
treatment, 339 

after-treatment, 342 
operative treatment, 340 
maxilla, inferior, 348 
after-care, 375 
diagnosis, 356 
etiology, 350 
prognosis, 375 
surgical anatomy, 348 
symptoms, 351 
treatment, 357 

after-treatment, 375 
operative treatment, 373 
superior, 343 
after-care, 346 
diagnosis, 345 
prognosis, 347 
surgical anatomy, 343 
symptoms, 344 
treatment, 345 

after-treatment, 346 
operative treatment, 346 
metacarpals, 297 
after-care, 306 
diagnosis, 300 
prognosis, 306 
surg-ical anatomy, 397 
symptoms, 299 
treatment, 301 

after-treatment, 306 
operative treatment, 305 
metatarsals, 714 
after-care, 718 
diagnosis, 718 
prognosis, 719 
surgical anatomy, 714 
symptoms, 716 
treatment, 718 

after-treatment, 718 
operative treatment, 718 
nasal bones, 323 
after-care, 332 
diagnosis, 327 



Fracture of, nasal bones — confd. 
etiology, 325 
prognosis, 333 
surgical anatomy, 323 
symptoms, 325 
treatment, 329 

after-treatment, 332 
operative treatment, 331 
navicular, 710 

treatment, 710 
nose, 323 (see Nasal bones) 
olecranon, 185 

OS calcis, 703 [see Calcaneum) 
patella, 594 
after-care, 605 
diagnosis, 597 
etiology, 595 
prognosis, 608 
surgical anatomy, 594 
symptoms, 595 
treatment, 598 

after-treatment, 605 
operative treatment, 600 
pelvis, 492 

complications, 509 

injury to, bladder, 510 
pelvic viscera, 509 
urethra, 509 
vessels, 509 
diagnosis, 505 
etiology, 496 
pathology, 496 
surgical anatomy, 492 
symptoms, 497 
treatment, 507 

of complications, 510, 511 
phalanges of foot, 720 
prognosis, 721 
surgical anatomy, 720 
symptoms, 720 
treatment, 720 
phalanges of hand, 307 
after-care, 312 
diagnosis, 310 
prognosis, 313 
surgical anatomy, 307 
symptoms, 308 
treatment, 310 

after-treatment, 312 
operative treatment, 311 
radius, lower end, 242 
after-care, 271 
Colles' fracture, 242 
diagnosis, 260 
prognosis, 273 
surgical anatomy, 242 
symptoms, 252 
treatment, 264 

after-treatment, 271 
operative treatment, 269 



INDEX 



801 



Fracture of — confd. 
shaft, 204 

after-care, 228 

diagnosis, 219 

prognosis, 229 

surgical anatomy, 204 

symptoms, 206 

treatment, 220 

after-treatment, 228 
operative treatment, 225 
upper end, 197 

after-care, 202 

diagnosis, 200 

prognosis, 203 

surgical anatomy, 197 

symptoms, 199 

treatment, 200 

after-treatment, 202 
operative treatment, 202 
ribs, 459 

after-care, 463 

diagnosis, 462 

emphysema in, 462 

prognosis, 464 

surgical anatomy, 459 

symptoms, 461 

treatment, 462 

after-treatment, 463 
scaphoid, 710 
scapula, 37 

acromion process, 40 

after-care, 43 

coracoid process, 40 

diagnosis, 41 

prognosis, 43 

surgical anatomy, 37 

symptoms, 40 

treatment, 42 

after-treatment, 43 
semilunar {see Carpus) 
semilunar cartilages, 587 

after-care, 592 

diagnosis, 590 

prognosis, 593 

surgical anatomy, 587 

symptoms, 588 

treatment, 591 

after-treatment, 592 
operative treatment, 591 
skull, 391 {see Skull, fractures of) 

diagnosis, 427 
differential, 429 

prognosis, 449 

surgical anatomy, 392 

symptoms, 411 

treatment, 444 

operative treatment, 447 
spine, 465 

after-care, 490 



Fracture of, spine — confd. 
diagnosis, 483 
prognosis, 491 
surgical anatomy, 465 
symptoms, 473 

cervical region, 481 
lumbar region, 482 
thoracic region, 482 
treatment, 484 

after-treatment, 490 
operative treatment, 486 
sternum, 453 
after-care, 458 
prognosis, 458 
surgical anatomy, 453 
treatment, 456 

after-treatment, 45i8 
operative treatment, 457 
tibia and fibula, lower ends, 675 
after-care, 683 
diagnosis, 679 
prognosis, 683 
surgical anatomy, 675 
symptoms, 675 
treatment, 681 

after-treatment, 683 
operative treatment, 682 
shafts, 634 

after-care, 654 
diagnosis, 642 
etiology, 637 
prognosis, 657 
surgical anatomy, 634 
symptoms, 638 
treatment, 642 

after-treatment, 654 
operative treatment, 650 
upper ends, 620 
after-care, 631 
diagnosis, 627 
etiology, 624 
prognosis, 633 
surgical anatomy, 620 
symptoms, 625 
treatment, 627 

after-treatment, 631 
operative treatment, 629 
ulna, lower end, 232 
after-care, 235 
diagnosis, 234 
prognosis, 236 
surgical anatomy, 232 
symptoms, 234 
treatment, 235 

after-treatment, 235 
operative treatment, 235 
shaft, 204 

after-care, 228 
diagnosis, 219 



802 



INDEX 



Fracture of, ulna, shaft — cont'd. 
prognosis, 229 
surgical anatomy, 204 
symptoms, 206 
treatment, 220 

after-treatment, 228 
operative treatment, 225 
upper end (olecranon), 185 
after-care, 195 
diagnosis, 190 
prognosis, 196 
surgical anatomy, 185 
symptoms, 188 
treatment, 190 

after-treatment, 195 
operative treatment, 191 
zygomatic arch, 334 (see Malar) 
Fracture-box, 643 

as double inclined plane, 582 
use of, 644 
Fractures, compound, treatment of, 
789 
open treatment of, 754 

absorbable suture material, 768 
asepsis in, 756 

cautions in closing wound, 758 
drainage, 758 
the four-post clamp, 763 
the Lane plate, 766 
use of screws, nails, etc., 759 
Freeman's clamp, 764 

G 

Grerman base line, 400 

Gerster's turn buckle, 762 

Glycosuria following head injuries, 
429 

Goldthwaite's splint, 311 

Grafting of bone, 771 

Gun-stock deformity, 

in dislocation of elbow, 158 
in fracture below elbow, 201 
in fracture of humerus, 128 

H 

Hammond's wire splint, 372 
Head injuries, 391 [see Skull, frac- 
ture of) 
compression, 410 
concussion, 407 
contusion, 408 
laceration, 409 
Heath splint, for fracture of man- 
dible, 363 
Heel, fracture of, 703 {see Calca- 

neum ) 
Hematoma of scalp, 382 
Hematomyelia, in fracture of spine, 
^ 479 



Hematorrhachis, in fracture of spine, 

479 
Hematuria, in fracture of pelvis, 509, 

511 
Hemorrhage, beneath skin {see Ec- 
chymosis ) 
into spinal cord, 479 
intracranial, 397 
meningeal, of cord, 579 
subdural, 397 
Hip, dislocation of, 515 
after-care, 530 
diagnosis, 523 
etiology, 520 
prognosis, 530 
surgical anatomy, 515 
symptoms, 520 
treatment, 524 

after-treatment, 530 
operative treatment, 529 
types, 519 
fracture of, 531 {see Xeck of fe- 
mur) 
after-care, 552 
diagnosis, 539 
etiology, 534 

injuries to femoral neck in chil- 
dren, 555 
prognosis, 555 
surgical anatomy, 531 
symptoms, 537 
treatment, 542 

after-treatment, 552 
operative treatment, 550 
Hodgen's splint, 582 
Hook, McBurney's, 72 
Humerus, dislocation of, 44 {see 
Shoulder, dislocation of) 
fracture of, lower end, 120 
after-care, 151 

crescentic fracture, 121, 123 
diagnosis, 136 
external condyle, 130 
external epicondyle, 129 
internal condyle, 131 
internal epicondyle, 131 
prognosis, 152 
surgical anatomy, 120 
symptoms, 128 
T-fracture, 134 
transverse fracture, 131 
treatment, 143 

after-treatment, 151 
operative treatment, 148 
shaft, 108 

after-care, 119 
diagnosis. 111 
musculo-spiral nerve in, 108, 

117, 119 
prognosis, 119 



INDEX 



803 



Humerus, fracture of shaft — cont'd. 
surgical anatomy, 108 
symptoms, 110 
treatment, 113 

after-treatment, 119 
operative treatment, 116 
vipper end, 82 
after-care, 106 
anatomical neck, 83 
diagnosis, 95 
dislocation of humeral liead 

complicating, 72-76 
etiolog;^', 89 

fracture of tuberosities, 85 
prognosis, 107 
separation of epiphysis, 88 
surgical anatomy, 82 
surgical neck, 8^ 
symptoms, 89 
treatment, 97 

after-treatment, 106 
operative treatment, 104 
Hysterical unconsciousness, 438 



I 



Iliac dislocation of hip, 517 

everted, 519 
Iliopectineal dislocation of hip, 518 
Ilium, fracture of, 498 {see Pelvis) 
Inclined plane, double, 580, 581, 582 

in fracture of thigh, 564 
Internal right-angle splint, 146 

with traction, 146 
Intracranial sinuses, 399 
Ischium, fracture of, 500 {see Pelvis) 



Jaw, loAver {see Maxilla, inferior) 
dislocation of, 376 
fracture of, 348 
upper, fracture of, 343 

K 

Kingsley's splint, 361 
Kocher's method of reducing disloca- 
tions of shoulder, 66, 67 
Knee, dislocation of, 613 
prognosis, 619 
surgical anatomy, 613 
symptoms, 616 
treatment, 617 

after-treatment, 619 
operative treatment, 618 



Laceration of brain, 409 



Laminectomy, 487 
Lane's bone drill, 760 
bone plates, 766 

Sherman's modification of, 765 
Leg, fractures of bones of, lower 
ends, 675 {see also Pott's 
fracture and ankle) 
after-care, 683 
diagnosis, 679 
prognosis, 683 
surgical anatomy, 675 
symptoms, 675 
treatment, 681 

after-treatment, 683 
operative treatment, 682 
shafts of, 634 
after-care, 654 
etiology, 637 
diagnosis, 642 
prognosis, 657 
surgical anatomy, 634 
symptoms, 638 
treatment, 642 

after-treatment, 654 
operative treatment, 650 
upper ends of, 620 
after-care, 631 
diagnosis, 627 
etiology, 624 
prognosis, 633 
surgical anatomy, 620 
symptoms, 625 
treatment, 627 

after-treatment, 631 
operative treatment, 629 
Ligaments, acromio-clavicular, 30 
capsular, of hip, 515 

of shoulder, 44 
of ankle, 685 
of clavicle, inner end, 5 

outer end, 30 
of elbow, 154 
of hip, 515 
of knee, 613, 614 
of shoulder, 44 
radio-ulnar, lower, 237 

upper, 177 
Y-ligament of Bigelow, 516 
Lothrop's operation in fractures of 

malar, 340 
Lumbar puncture in fracture of 

skull, 449 
Lung, puncture of, in fracture of 

ribs, 462 
Luxatio erecta, 61 
Luxations {see Dislocations) 



U 



Madelung's deformity, 239 



804 



INDEX 



Malar bone, fracture of, 334 
after-care, 342 
diagnosis, 338 
etiology, 336 
prognosis, 342 
surgical anatomy, 334 
sYmptoms, 336 
treatment, 339 

after-treatment, 342 
operative treatment, 340 
Mandible {see Maxilla, inferior) 
Massage {see After-treatment) 
Matas splint, 362 
Maxilla, inferior, 

dislocation of, 376 
etiology, 377 
prognosis, 378 
surgical anatomy, 376 
symptoms, 377 
treatment, 377 

after-treatment, 378 
fracture of, 348 
after-care, 375 
diagnosis, 356 
prognosis, 375 
surgical anatomy, 34i8 
symptoms, 351 
treatment, 357 

after-treatment, 375 
operatiA'e treatment, 373 
superior, fracture of, 343 
after-care, 346 
diagnosis, 345 
prognosis, 347 
surgical anatomy, 343 
symptoms, 344 
treatment, 345 

after-treatment, 346 
operative treatment, 346 
McBurney's hook, 72 
Measurements in {see Diagnosis) 
fracture of femur, 539 
of humerus, 96 
Medio-tarsal joint, dislocations of, 
709 
surgical anatomy, 7U9 
treatment, 709 
Meninges, of brain, 395 

vessels of, 396 
Meningitis, differentiated from frac- 
ture of skull, 443 
Metacarpal bones, dislocations of, 
294 {see Carpo-metacar- 
pal luxations) 
fractures of, 297 
after-care, 306 
diagnosis, 300 
prognosis, 306 
surgical anatomy, 297 
symptoms, 299 



Metacarpal bones, fractures of — 
cont'd. 
treatment, 301 

after-treatment, 306 
operative treatment, 305 
Metal numbers for marking X-ray 

plates, 704 
Metatarsal bones, dislocations of, 
713 {see Tarso-metatarsal 
luxations ) 
fractures of, 714 
after-care, 718 
diagnosis, 718 
prognosis, 719 
surgical anatomy, 714 
symptoms, 716 
treatment.- 718 

after-treatment, 718 
operative treatment, 718 
Middledorf triangle, 102 
Mohr's figure-of-eight bandage, 25 
Musculo-spiral nerve in fractures of 
humerus, 108, 117, 119 
N 
Nasal bones, fractures of, 323 
after-care, 332 
diagnosis, 327 
etiology, 325 
prognosis, 333 
surgical anatomy, 323 
symptoms, 325 
treatment, 329 

after-treatment, 332 
operative treatment, 331 
Navicular of tarsus, 710 
prognosis, 712 
surgical anatomy, 710 
treatment, 710 

after-treatment, 712 
operative treatment, 712 
Neck, anatomical, of humerus, 83 
{see Humerus) 
of femur, 532, 537 {see Femur) 
of scapula, 40 {see Scapula) 
surgical, of humerus, 87, 92 {see 
Humerus ) 
Neck, fractures of, 465 {see Spine, 

fracture-dislocations of) 
Nelaton's line, 533, 534, 539 
Nerves, cranial, in fracture of skull, 
394 
exists through base, 394 
symptoms of injury to, 425 
Nichols traction apparatus, 569 
Nose, fracture of, 323 {see Nasal 
bones) 


Olecranon, fracture of, 185 {see 
Ulna) 



INDEX 



805 



Olecranon, fracture of — cont'd. 
after-care, 195 
complicating luxations of elbow, 

166 
diagnosis, 190 
prognosis, 196 
surgical anatomy, 185 
symptoms, 188 
treatment, 190 

after-treatment, 195 
operative treatment, 191 
Oliver's method of wiring jaws to- 
gether, 366 
Operative treatment of compound 
fractures and disloca- 
tions, 7^9 
Operative treatment, 

of dislocations of ankle, 690 
astragalus, 697 
calcaneum, 706 
carpal bones, 292 
carpo-metacarpal joint, 296 
clavicle, inner end, 9 

outer end, 36 
elbow, 170 
lingers, 318 
hip, 529 
OS calcis, 706 
patella, 611 

phalanges of hand, 318 
radius, head of, 181 
semilunar cartilages, 591 
shoulder, 71 
spine, 486 (see Spine) 
subastragalar joint, 701 
ulna, lower end, 240 

upper end, 176 
wrist, 292 
in fracture of, astragalus, 697 
calcaneum, 706 
carpus, 292 
clavicle, 26 
coccyx, 508 
cuboid, 712 
cuneiforms, 712 
femur, lower end, 582 
shaft, 569 
upper end, 550 
fibula, lower end, 651, 682, 690 
shaft, 650 
upper end, 629 
fingers, 311 
hip, 550 

humerus, lower end, 148 
shaft, 116 
upper end, 104 
jaw, lower, 373 

upper, 346 
malar, 340 
maxilb, inferior, 373 



Operative treatment, in fracture of— - 
cont'd. 
superior, 346 
metacarpals, 305 
metatarsals, 718 
nasal bones, 331 
olecranon, 191 
OS calcis, 706 
patella, 600 

phalanges of hand, 310 
radial and ulnar shafts, 225 
radius, lower end, 269 
shaft, 225 
upper end, 202 
scaphoid, 712 
semilunar cartilages, 591 
skull, 447 
spine, 486 
sternum, 457 

tibia and fibula, lower ends, 682 
shafts, 650 
upper ends, 629 
ulna, lower end, 235 
shaft, 225 
upper end, 191 
zygomatic arch, 340 
in Colles' fracture, 269 
in Pott's fracture, 671 
Os calcis, fractures and dislocations 
of, 703 
after-care, 707 
diagnosis, 706 
prognosis, 708 
surgical anatomy, 703 
symptoms, 705 
treatment, 706 

after-treatment, 707 
operative treatment, 706 
Osgood-Penhallow splint, 102 
Os magnum, fractures and disloca- 
tions of, 277 {see Carpus) 
Osteitis of carpus following Colics' 

fracture, 274 
Osteogenesis imperfecta, 732, 733 



Packing of nasal cavities in fracture 

of nose, 329 
Pad, axillary in fracture of humerus, 

98, 99, 101, 114 
Passive motion after {see After- 
treatment ) 
Colles' fracture, 272 
dislocation of, elbow, 172 
fingers, 381 
shoulder, 79 
thumb, 381 
fracture of, clavicle, 29 
olecranon, 195 
patella, 606 



806 



INDEX 



Passive motion after — cont'd. 
injuries to carpus, 292 
Pott's fracture, 673 
Patella, dislocation of, 609 
after-care, 612 
diagnosis, 611 
etiology, 610 
prognosis, 612 
surgical anatomy, 609 
symptoms, 610 
treatment, 611 

after-treatment, 612 
operative treatment, 611 
fracture of, 594 
after-care, 605 
diagnosis, 597 
etiology, 595 
prognosis, 608 
surgical anatomy, 594 
symptoms, 595 
treatment, 598 

after-treatment, 605 
operative treatment, 600 
PatholoQJc fractures, 728-733 
Pelvis, fracture-dislocations of, 492 
diagnosis, 505 
etiology, 496 
pathology, 496 
surgical anatomy, 492 
symptoms, 497 
treatment, 507 

of complications, 510, 511 
of rupture of bladder, 511 
of rupture of urethra, 510 
Penhallow, Osgood-Penhallow splint, 

102 
Perineal dislocation of hip, 518 
Phalanges, of foot, 720 {see Toes) 
of hand (see Fingers) 
dislocations of, 314 
fracture of, 307 
Plate, Lane's, 766 

Plaster of Paris, use of in fractures 
of femur, 546, 568 
of hip, 546 

of humerus, 100, 103, 147 
of leg, 648 
of metacarpals, 305 
of metatarsals, 718 
of pelvis, 50i8 
of spine, 484 
Pneumonia following fractures of 
hip, 542 
of ribs, 464 
Pott's fracture. 659 
after-care, 673 
diagnosis, 666 
prognosis, 673 
surgical anatomy, 659 
symptoms, 664 



Pott's fracture — cont'd. 
treatment, 668 

after-treatment, 673 
operative treatment, 671 
Prognosis, in dislocations of, 
ankle, 691 
astragalus, 698 
calcaneum, 708 
carpal bones, 293 
carpo-metacarpal joint, 296 
clavicle, inner end, 10 

outer end, 36 
cuboid, 712 
elbow, 174 
fingers, 319 
hip, 530 
jaw, 378 . 
knee, 619 
mandible, 378 
maxilla, 378 
OS calcis, 708 
patella, 612 
phalanges of foot, 721 

of hand, 319 
radius, head of, 183 
semilunar cartilages, 593 
shoulder, 80 
spine, 491 

subastragalar joint, 702 
ulna, lower end, 241 

upper end, 176 
fracture of, 

astragalus, 698 
calcaneum. 708 
carpus, 293 
clavicle, 29 
cuboid, 712 
cuneiforms, 712 
femur, lower end, 586 

shaft, 573 

upper end, 555 
fibula, lower end, 673, 683, 691 

shaft, 657 

upper end, 633 
fma'ers. 313 
hip, 555 
humerus, lower end, 152 

shaft, 119 

upper end. 107 
inferior maxilla, 375 
jaw, lower, 375 

upper, 347 
malar. 342 
maxilla, inferior, 375 

superior. 347 
metacarpals, 306 
metatarsals, 719 
nasal bones. 333 
olecranon, 196 
OS calcis, 708 
patella, 608 



INDEX 



807 



Prognosis, fracture of — cont'd. 
phalanges of foot, 721 

of hand. 312 
radial and ulnar shafts, 229 
radius, lower end, 236 
shaft, 229 
upper end, 203 
ribs, 464 
scaphoid, 712 
scapula, 43 

semilunar cartilages, 593 
spine, 491 
st€rnum, 458 
superior maxilla, 347 
tibia and fibula, lower ends, 6S3 
shafts, 657 
upper ends, 633 
ulna, lower end, 236 
shaft, 229 
upper end, 196 
zygomatic arch, 342 
of Colles' fracture, 236 
of Pott's fracture, 673 
Pubic dislocation of hip, 573 
Pulse, in fracture of skull, 422 
Puncture, lumbar, in fracture of 

skull, 449 
Puncture of lung in fracture of ribs, 

462 
Pupils, reaction of, in fracture of 
skull, 423 
in various types of coma {see Dif- 
ferential diap'nosis in frac- 
ture of skull, 429) 



Q 



Qualimeter, Bauer's, 746 



R 



Eachitis as cause of fracture, 732, 

733 
Padio-chronometer, 746 
Padio-ulnar ligaments, lower, 237 

upper, 177 
Radius, dislocation of upper end, 177 
after-care, 182 
diagnosis, 180 
prognosis, 183 
surgical anatomy, 177 
symptoms, 178 
treatment, 180 

after-treatment, 182 
operative treatment, 181 
fracture of, lower end, 242 
after-care, 271 
diagnosis, 260 
prognosis, 273 
surgical anatomy, 242 
symptoms, 252 



Radius, fracture of — cont'd. 
treatment, 264 

after-treatment, 271 
operative treatment, 269 
of shaft, 204 
after-care, 228 
diagnosis, 219 
prognosis, 229 
surgical anatomy, 204 
symptoms, 206 
treatment, 220 

after-treatment, 228 
operative treatment, 225 
of upper end, 197 
after-care, 202 
diagnosis, 200 
prognosis, 203 
surgical anatomy, 197 
symptoms, 199 
treatment, 200 

after-treatment, 202 
operative treatment, 202 
Reduction of {see Treatment) 
Reflexes in {see Symptoms) 

coma from various causes, 429 {see 
Differential diagnosis of 
fracture of skull) 
fracture of skull, 423 
of spine, 480 
Respiration in coma, from vari'^us 
causes, 429 
in fracture of ribs, 461 
of skull, 422 
of sternum, 426 
Reversed Colles' fracture, 244 
Reversed Pott's fracture, 664 
Ribs, fractures of, 459 
after-care, 463 
diagnosis, 462 
prognosis, 464 
surgical anatomy, 459 
symptoms, 461 
treatment, 462 

after-treatment, 463 
T^olando, fissure of, 401 
Rontgen ray in diagnosis and treat- 
ment of fractures and 
luxations, 735 
Rose portable coil, 738, 739 
Ruth-Maxwell method in fracture of 
hip, 545 



Sacro-iliac synchondrosis, 504 
Sarcoma as cause of fracture, 730 
Sayre's dressing (modified) in dislo- 
cations of clavicle, 9 

in fracture of clavicle, 24 

in fracture of scapula, 42 



808 



INDEX 



Scalp wounds, 379 
after-care, 390 
complications, 384 
pathology, 382 

recognition of complications, 389 
sequelae, 384 
surgical anatomy, 379 
symptoms, 382 
treatment, 385 

closure of wound, 389 
control of hemorrhage, 385 
prevention of infection, 388 
varieties, 383, 384 
Scaphoid of carpus, dislocations of, 
286 
"divided," 283 
fracture of, 286 
Scapula, fracture of, 37 
after-care, 43 
diagnosis, 41 
prognosis, 43 
surgical anatomy, 37 
symptoms, 40 
treatment, 42 

after-treatment, 43 
Sciatic dislocation of hip, 517 
Screw-plate, Author's, 550, 551 
Semilunar, fracture of {see Carpus) 
Semilunar cartilages, fractures and 
dislocations of, 587 
after-care, 592 
diagnosis, 590 
prognosis, 593 
surgical anatomy, 597 
symptoms, 588 
treatment, 591 

after-treatment, 592 
operative treatment, 591 
Separations, epiphyseal, considered 
under fracture of bone in 
question (see Fracture) 
Sherman's modification of Lane's 
plate, 765, 766 
tap-screw, 766 
Shoulder, dislocation of, 44 
after-care, 79 
diagnosis, 64 
etiology, 51 

fracture complicating, 72 
old dislocations, 77 
prognosis, 80 
recurrent dislocations, 77 
surgical anatomy, 44 
symptoms, 52 
treatment, 66 

after-treatment, 79 
horizontal traction in, 69 
Kocher's method in, 66, 67 
operative treatment, 71 
Stimson's method in, 69 



Shoulder, dislocation of — cont'd. 

tvpes, 49 
Silver fork deformitv, 252-259 
Skull, fractures of, 391 
diagnosis, 427 
differential from, 

abscess of brain, 443 
alcoholic coma, 433 
apoplectiform and epileptiform 

convulsions, 443 
apoplexy, 440 
asphyxia from gas, 435 
cerebral anemia, 432 
cerebral congestion, 432 
cerebral embolism, 440 
cerebral hemorrhage, 441 
cerebral syphilis, 442 
cerebral thrombosis, 441 
coma of acute infections, 438 
diabetic coma, 437 
epilepsy, 439 
epileptiform attacks, 443 
feigning, 438 
hysteria, 438 

poisoning by, belladonna, 436 
alcohol, 433 
chloral, 435 
hyocvamus, 436 
lead,' 436 
opium, 434 
phenol, 434 
ptomaines, 435 
shock, 431 
syncope, 431 
tumor of brain, 443 
uremic coma, 436 
etiology, 404 

mechanism and pathology, 405 
fracture by, bending, 405 
bursting, 405 
contre coup, 406 
gunshot fractures, 407 
prognosis, 449 
surgical anatomv, 392 
bones of skull, 392 
cortical centers, 399 
formation of, base, 393 

vault, 392 
membranes of brain, 395 

vessels of, 396 
meningeal vessels, 396 
sinuses, intracranial, 399 
symptoms, 411 
aphasias, 424 
classification of, 412 
compression, 410 
concussion, 407 
contusion, 408 

cranial nerve symptoms, 425 
depressions in bone, 413 



INDEX 



809 



Skull, fractures of, symptoms— 
confd. 
deviations in eyes, 422 
disturbed psychic function, 424 
eccliymosis, 418 
emphysema, 420 
escape of blood and brain, 417 
general flaccidity, 421 
headache, 421 
laceration, 409 

late symptoms and sequeltp, 450 
chronic headache, 451 
disturbances in hearing, 451 
epilepsy, 451 
psychic changes, 452 
vertigo, 451 
vomiting, 451 
weakness of intellect, 452 
localizing, 423 
mobility and crepitus, 413 
pain in region of fracture, 413 
pulse in, 422 
pupillary reactions, 423 
reflexes, deep, of two sides, 423 
respiration, 422 
temperature, 422 

of two sides, 424 
unconsciousness, 420 
A^omiting, 420 
vertigo, 421 
treatment, 444 

catheterization, 445 
electric heat blanket, 444 
hot Avater bottles, 444 

dangers of, 444 
nasal and oral cavities, 446 
operative treatment, 447 
elevation of fragments, 447 
osteoplastic flap, 448 
sedatives, 445 
stimulation, 445 
the ear, 446 
Smith, R. E., splint, 646 
Spine, fracture-dislocations of, 465 
after-care, 490 
diagnosis, 483 
prognosis, 491 
surgical anatomy, 465 
symptoms, 473 
treatment, 484 

after-treatment, 490 
operative treatment, 486 
Splints, 

ambulatory pneumatic, 554, 585, 

655 
Cabot wire splint, 580, 646 
Cobb's nasal, 330 
Desault, 645 
Dupuy's, 581 

for Colles' fracture, 223, 265, 266, 
267 



Splints — cont'd. 

for fractures of fingers, 309, 310, 

311 
for fractures of forearm, 223 
for fracture of metacarpals, 304 
for fracture of patella, 598, 599 
for Pott's fracture, 668, 669 
Dupuytren's, 668 
Stimson's, 669 
Cxoldthwaite's, 311 
Ham, 599 

Hammond's wire, 372 
Heath's, 363 
Hogden's, 582 
Kingsley's, 361 
Matas', 362 

Osgood-Penhallow's, 102 
plaster, for fractures of humerus, 
147 
for fracture of leg, 648 
right-angle, 146 
Smith's, 646 
straight, in fracture of olecranon, 

191 
T-splint, 544 
Thomas' hip, 549 
Walker's, 266 
Stereoscopic X-ray plates, 74, 751 
Sternum, fracture of, 453 
after-care, 458 
prognosis, 458 
surgical anatomy, 453 
treatment, 456 

after-treatment, 458 
operative treatment, 457 
Stimson's dressing for dislocations 
of outer end of clavicle, 
35 
method of reducing dislocations of 

hip, 526 
method of reducing dislocations of 

shoulder, 69 
splints, 669 
Strapping, of chest, for fracture of 
ribs, 463 
of scapula, 402 
Stromeyer cushion, 114 
Structure of, clavicle, 12 
femur, lower end, 575 
shaft, 575 
upper end, 531 
humerus, upper end, 83 
patella, 600 
Styloid of ulna, fracture of, 232 
Subastragalar joint, dislocation of, 
699 
after-care, 702 
diagnosis, 701 
prognosis, 702 
surgical anatomy, 699 



810 



INDEX 



Subastragalar joint, dislocation of — 
confd. 
symptoms, 700 
treatment, 701 

after-treatment, 702 
operative treatment, 701 
Subcoracoid dislocation of clavicle, 
33 
of shoulder, 50, 52 
Subglenoid dislocation of shoulder, 

51, 58 
Superior maxilla, fracture of, 343 
Surgical anatomv of, dislocation of, 
ankle, 684 ' 
astragalus, 692 
calcaneum, 703 
carpo-metacarpal joint, 294 
clavicle, inner end, 5 

outer end, 30 
cuboid, 710 
elbow, 154 
fingers, 314 
hip, 515 
jaw, 376 
knee, 613 
mandible, 376 
maxilla, 376 
mediotarsal joint, 709 
OS calcis, 703 
patella, 609 
pelvis, 492 
phalanges of foot, 720 

of hand, 314 
radius, head of, 177 
scapula, 37 

semilunar cartilages, 587 
shoulder, 44 
spine, 465 

subastragalar joint, 699 
tarso-metatarsal joint, 713 
ulna, lower end, 237 

upper end, 175 
wrist, 277 
fracture of, astragalus, 692 
calcaneum, 703 
carpus, 277 
clavicle, 1 1 
cuboid, 710 
cuneiforms, 710 
femur, lower end, 574 

shaft, 558 

upper end, 531 
fibula, lower end, 675 

shaft, 634 

upper end, 620 
fingers, 307 
hip, 531 
humerus, lower end, 120 

shaft, 108 

upper end, 82 



Surgical anatomy of, fracture of — 
confd. 
inferior maxilla, 348 
jaw, lower, 348 

upper, 343 
malar, 334 
maxilla, inferior, 348 

superior, 343 
metacarpals, 297 
metatarsals, 714 
nasal bones, 323 
olecranon, 185 
OS calcis, 703 
patella, 594 
pelvis, 492 
phalanges of foot, 720 

of hand, 307 
radial and ulnar shafts, 204 
radius, lower end, 242 
shaft, 204 
upper end, 197 
ribs, 459 
scaphoid, 710 
scapula, 37 

semilunar cartilages, 587 
skull, 392 
spine, 465 
sternum, 453 
superior maxilla, 343 
tibia and fibula, lower ends, 675 
shafts, 634 
upper ends, 620 
ulna, lower end, 232 
shaft, 204 
upper end, 185 
zygomatic arch, 334 
of Colles" fracture, 242 
of Pott's fracture, 659 
of scalp wounds, 379 
Surgical neck, of humerus, fracture 
of, 87 
complicatino- dislocations of 

shoulder, 72 
relations of, to circumflex nerve, 
105 
of scapula, fracture of, 40 
Suture of fragments (see Open treat- 
ment of fractures) 
Suture materials in treatment of 

fractures, 768 
Suturing of fascia in fracture of pa- 
tella, 602 
Swathe, in fracture of, humerus, 101. 
104 
pelvis, 507 
ribs, 464 
with long side splint, 544 
Symptoms, of dislocations of, 
ankle, 687 
astragalus, 694 



INDEX 



811 



Symptoms, of dislocations of — cont'd. 
calcaneum. 705 
carpo-metaearpal joint, 205 
clavicle, inner end, 6 

outer end, 32 
elbow, 156 
lingers, 317 
hip, 520 
jaw, 377 
knee, 016 
mandible, 377 
maxilla, 377 
OS calcis, 705 
patella, 610 
pelvis, 497 
phalanges of foot, 720 

of hand, 317 
radius, head of, 178 
semikmar cartilages, 588 
shoulder. 52 
spine, 473 

subastragalar joint, 700 
tarso-metatarsal joint, 713 
ulna, lower end, 238 

upper end, 175 
fractures of, astragalus, 694 
calcaneum, 705 
carpus, 287 
clavicle, 15 
coccyx, 500 
femur, lower end, 578 

shaft, 561 

upper end, 537 
fibula, lower end, 675 

shaft, 638 

upper end, 625 
fingers, 308 
hip, 537 
humerus, lower end, 128 

shaft, 110 

upper end, 89 
inferior maxilla, 351 
jaw, lower, 351 

upper, 344 
malar, 366 
maxilla, inferior, 351 

superior, 344 
metacarpals, 299 
metatarsals, 716 
nasal bones, 325 
olecranon, 188 
OS calcis, 705 
patella, 595 
pelvis, 497 
phalanges of foot, 720 

of hand, 308 
radial and ulnar shafts, 206 
radius, lower end, 252 

shaft, 206 

upper end, 199 



Symptoms, fractures of — confd. 
ribs, 461 
scapula, 40 

semilunar cartilages, 588 
skull, 411 
spine, 473 

superior maxilla, 344 
tibia and fibula, lower ends, 675 
, shafts, 638 

upper ends, 625 
ulna, lower end, 234 
shaft, 206 
upper end, 188 
zygomatic arch, 366 
of Colles' fracture, 252 
of Pott's fracture, 664 
of scalp wounds, 382 
Symphysis pubis, separation of, 502 
Syphilis as a cause of fracture, 730 
Svphilitic deformitv of nasal bones, 
327, 328' 



T-splint, 544 

Tarso-metatarsal joint, dislocation 
of, 713 
diagnosis, 713 
surgical anatomy, 713 
symptoms, 713 
treatment, 713 
Taylor brace for fracture of clavicle, 

27 
Teeth, loss of alignment in, 

fracture of inferior maxilla, 351- 

356 
fracture of superior maxilla, 345 
Temperature, in fracture of skull, 
422 
in various forms of unconscious- 
ness, 429 
Terms, 725 

Thomas hip splint, 549 
Tibia and fibula, fracture of, 
lower ends, 675 
after-care, 683 
diagnosis, 679 
prognosis, 683 
surgical anatomy, 675 
symptoms, 675 
treatment, 681 

after-treatment, 683 
operative treatment, 682 
shafts, 634 

after-care, 654 
diagnosis, 642 
etiology, 637 
prognosis, 657 
surgical anatomy, 634 
symptoms, 638 



812 



INDEX 



Tibia and fibula, sliafts — cont'd. 
treatment. 642 

after-treatment, 654 
operative treatment, 650 
upper ends, 620 
after-care, 631 
diagnosis, 627 
etiology, 624 
prognosis, 633 
surgical anatomy, 620 
symptoms, 625 
treatment, 627 

after-treatment, 631 
operative treatment, 629 
Tibial tubercle, anomalous ossifica- 
tion of, 622 
injury to, 622 
'Tipping" of, 621 
Toes, fracture-dislocations of, 720 
prognosis, 721 
surgical anatomy, 720 
symptoms, 720 
treatment, 720 
Transplantation of bone, 771 
Traumatic fiat-foot, 673, 708 
Treatment of compound fractures 

and luxations, 789 
Treatment of, dislocation of, 
ankle, 689 
astragalus, 695 
calcaneum, 706 
carpal bones, 291 
carpo-metacarpal joint, 296 
clavicle, inner end, 7 

outer end, 34 
elbow, 167 
fingers, 317 
liip, 524 

inferior maxilla, 377 
knee, 617 

maxilla, inferior, 377 
mediotarsal joint, 709 
OS calcis. 706 
patella, 611 
pelvis, 507 
phalanges of foot, 720 

of band, 317 
semilunar cartilages, 591 
shoulder, 66 
spine. 484 

subastragalar joint, 701 
tarso-metatarsal joint." 713 
thumb. 317 
ulna, lower end, 239 

upper end, 176 
wrist, 291 
fracture of, acetabulum. 507, 530 
acromion, 42 
astragalus, 695 
bones of forearm, shafts, 220 



Treatment of, fracture of — confd. 
calcaneum, 706 
carpal bones, 291 
clavicle, 22 
cuboid, 710 
cuneiforms, 710 
femur, lower end, 580 

shaft, 563 

upper end, 542 
tlbuia, lower end, 658, 681, 689 

shaft, 642 

upper end, 627 
fingers, 310 
humerus, lower end, 143 

shaft, 113 

upper end, 97 
malar, 339 
maxilla, inferior, 357 

superior, 345 
metacarpal bones, 301 
metatarsal bones, 718 
nasal bones, 329 
olecranon, 190 
OS calcis, 706 
patella, 598 
pelvis, 507 
phalanges of foot, 720 

of hand, 310 
radial and ulnar shafts, 220 
radius, lower end, 264 

shaft, 220 

upper end, 220 
ribs, 462 
scaphoid, 710 
scapula, 42 

semilunar cartilages, 591 
skull, 444 
spine, 484 
sternum. 456 
tibia and fibula, lower ends, 681 

shafts, 642 

upper ends, 627 
ulna, lower end. 235 

shaft, 220 

upper end, 190 
zygomatic arch, 339 
of Barton's fracture, 269 
of Bennett's fracture, 305 
of Colles' fracture, 264 
of Pott's fracture, 668 
of scalp wounds, 385 
recumbent, of fractured clavicle, 25 
Triangulare, 279 
Trigonum, 703 

Tuberosities of humerus, fracture of, 85 
Turn -buckles, Gerster's, 762 

U 
Ulna, dislocations of lower end, 237 
after-care, 240 



INDEX 



813 



Ulna, dislocations of lower end — 
confd. 
diagnosis, 239 
prognosis, 241 
surgical anatomy, 237 
symptoms, 238 
treatment, 239 

after-treatment, 240 
operative treatment, 240 
upper end, 175 
after-care, 176 
prognosis, 176 
surgical anatomy, 175 
symptoms, 175 
treatment, 176 

after-treatment, 176 
operative treatment, 176 
fracture of lower end, 232 
after-care, 235' 
diagnosis, 234 
prognosis, 236 
surgical anatomy, 232 
symptoms, 234 
treatment, 235 

after-treatment, 235 
operative treatment, 235 
of shaft, 204 
after-care, 228 
diagnosis, 219 
prognosis, 229 
surgical anatomy, 204 
symptoms, 206 
treatment, 220 

after-treatment, 228 
operative treatment, 225 
upper end (olecranon), 185 
after-care, 195 
diagnosis, 190 
prognosis, 196 
surgical anatomy, 185 
symptoms, 188 
treatment, 190 

after-treatment, 195 
operative treatment, 191 
Unciform {see Carpus) 
Unconsciousness from fracture of 
skull, differential diagno- 
sis of, 429 
Union of fragments, time necessary 
{see Prognosis of various 
chapters ) 



Uremic coma, 436 

Urethra, injury to, and rupture of, 
in fracture of pelvis, 509 
Use of, four-post clamp, 763 

Lane plate, 766 

nails, screws and peg, 759 

wire, 758 

X-ray, 735 



Velpeau's bandage, 25 

in dislocation of clavicle, 9 
Vertebrae, fracture of {see Spine) 
Vertical suspension in fracture of 

femur in children, 565 
Vertigo in fracture of skull, 421 
Vessels, meningeal, 396 
Visceral lesions in fracture of pelvis, 

509 
Volkmann's contracture, 231 
Vomiting in head injuries, 420 



W 



Walker's splint for Colics', 226 
Whitman, treatment of fracture of 

femoral neck in children, 

557 
Wire nails, 754 
W'ire, use of, in fractures, 7518 
Wounds of compound fractures, 789 
Wounds of scalp, 379 
W^rist {see Carpus) 



X 



X-ray, use of, 735 



Y-ligament of Bigelow, 516 



Zygomatic arch, fracture of, 334 
{see Malar) 












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